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 ["12"]
Explanation
1. Convert the child's weight from pounds to kilograms:
There are approximately 2.2 pounds in 1 kilogram.
33 pounds / 2.2 pounds/kg = 15 kg (approximately)
2. Calculate the total milligrams of amoxicillin needed per dose:
The order is for 20 mg/kg/dose.
The child weighs 15 kg.
20 mg/kg * 15 kg = 300 mg
3. Determine the concentration of the amoxicillin suspension:
The label shows the concentration is 125 mg/5 mL.
4. Set up a proportion to find the volume (in mL) needed:
125 mg / 5 mL = 300 mg / x mL
5. Solve for x:
Cross-multiply: 125x = 300 * 5
125x = 1500
x = 1500 / 125
x = 12 mL
Answer: You will administer 12 mL per dose.
Correct Answer is C
Explanation
A) Prepare and administer the prescribed antidote: Administering an antidote would only be appropriate if the medication error resulted in a harmful reaction that requires immediate reversal. Since the issue here is the timing of medication administration, it is more important to first assess the client for any immediate effects rather than administering an antidote, which might not be necessary at this stage.
B) Notify the charge nurse, the nurse manager, and the prescriber: While notifying the appropriate staff is crucial, the first action should be assessing the client for any safety concerns or complications resulting from the medication administration error. Immediate evaluation of the client's condition should take precedence over notification.
C) Assess and identify the presence of urgent safety issues: The first priority in this situation is to assess the client for any adverse effects or reactions due to the medication being administered too quickly. This could include monitoring for signs of toxicity, adverse reactions, or changes in vital signs that may indicate a potential risk to the client’s health. Once the client's status is assessed, further actions such as notifying other staff or completing an incident report can follow.
D) Complete an incident report detailing the error: While documenting the error in an incident report is necessary, this should not be the first step. The immediate priority is to ensure the client’s safety by assessing their condition, as an error in the timing of medication administration may result in unwanted side effects or complications that need to be addressed first.
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