A nurse assesses the client and determines the client is at risk for unstable blood glucose. Which activity best reflects the planning phase of the nursing process?
The nurse demonstrates to the client how to perform a blood glucose test using the glucometer.
The nurse formulates a goal of "The client will have a blood sugar between 120-180 for the entire shift
The nurse administers the ordered subcutaneous injection of insulin to the client.
The nurse uses a glucometer to check the client's blood glucose level via a finger stick.
The Correct Answer is B
This action reflects the planning phase of the nursing process, where the nurse sets measurable and achievable goals based on the client's assessment data.
Here’s how the other options fall into different phases:
A. Demonstrating how to perform a blood glucose test = Implementation (teaching/intervention).
C. Administering insulin = Implementation (carrying out an intervention).
D. Checking blood glucose level = Assessment (gathering data).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Lying flat on the back: Positioning the client flat on their back is not the most effective position for administering a rectal suppository. The correct position allows for easier insertion and proper absorption of the medication. Lying flat on the back may make it difficult for the nurse to administer the suppository in the correct manner.
B) Lying flat on the stomach: Lying flat on the stomach is not recommended for the administration of a rectal suppository, as it can be uncomfortable for the client and can impede the ability to access the rectal area. The side-lying position is more effective for both client comfort and proper placement of the suppository.
C) Left side-lying: The left side-lying position, often referred to as the Sims' position, is the most appropriate for administering a rectal suppository. This position helps to expose the rectal area, allows for easier insertion, and promotes the suppository’s absorption, as gravity can assist in its positioning within the rectum.
D) Right side-lying: The right side-lying position is not as effective as the left side-lying position for the administration of a rectal suppository. The left-side position helps to ensure the smooth placement of the suppository and promotes its absorption. Therefore, the right side is not the optimal choice.
Correct Answer is D
Explanation
A) Peptic ulcer: Scopolamine is an anticholinergic medication that works by blocking acetylcholine, which can reduce nausea and motion sickness. While scopolamine can have anticholinergic effects that may slightly reduce gastric motility, it is not directly contraindicated in clients with a history of peptic ulcer. The medication does not significantly exacerbate the condition of peptic ulcers.
B) Asthma: While scopolamine can have anticholinergic effects that may lead to dry mouth and slight airway narrowing, it is not contraindicated in clients with asthma. However, the nurse should be cautious and monitor the client for any signs of respiratory distress, as anticholinergic medications can cause some bronchial smooth muscle relaxation, which could theoretically worsen asthma symptoms. It is not an absolute contraindication.
C) Heart disease: Scopolamine is not specifically contraindicated for individuals with heart disease, although caution should be used in patients with cardiovascular conditions due to its potential effects on heart rate and blood pressure. However, heart disease itself is not a direct contraindication for the use of scopolamine.
D) Glaucoma: Scopolamine is an anticholinergic medication, and anticholinergics can increase intraocular pressure. This is especially dangerous for clients with narrow-angle glaucoma, as the medication can exacerbate the condition, leading to a potential acute glaucoma attack. Therefore, individuals with a history of glaucoma, particularly narrow-angle glaucoma, should avoid scopolamine.
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