During the planning phase of the nursing process, which action should a nurse prioritize for a diabetic patient with consistently high blood glucose levels?
Set a goal to maintain blood glucose levels within normal range
Document the patient's blood glucose readings.
Teach the patient about carbohydrate counting
Administer insulin as prescribed.
The Correct Answer is A
A. Set a goal to maintain blood glucose levels within normal range: In the planning phase, establishing measurable and achievable goals is the priority. Setting a target for blood glucose guides the development of interventions and provides a benchmark for evaluating the effectiveness of care.
B. Document the patient's blood glucose readings: Documentation is part of the implementation and evaluation phases. While important for tracking trends, it does not establish the direction of care or plan interventions.
C. Teach the patient about carbohydrate counting: Patient education is an intervention that supports achieving the goal, but it cannot be implemented effectively without first defining the desired outcome.
D. Administer insulin as prescribed: Administering insulin is an implementation action. While critical for management, it is guided by the plan and goals set during the planning phase, rather than being the initial planning step.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Recheck the blood pressure after 5 minutes of rest: Blood pressure can be temporarily elevated due to stress, activity, or anxiety (“white coat effect”). Reassessing after the patient has rested ensures an accurate measurement before making clinical decisions or initiating treatment.
B. Immediately administer antihypertensive medication: Initiating medication without confirming persistent elevation and evaluating for underlying causes is inappropriate. Accurate assessment is needed before starting therapy.
C. Schedule follow-up in 6 months: Waiting six months without reassessment risks missing persistent hypertension, which can lead to cardiovascular complications. Follow-up should be sooner after confirming the measurement.
D. Advise the patient to lower salt intake immediately: Dietary counseling is important for hypertension management, but it is not the priority initial action. Confirming the elevated blood pressure first guides appropriate interventions.
Correct Answer is A
Explanation
A. Assess for signs of hypoxia and respiratory distress: A respiratory rate of 28 breaths/min indicates tachypnea and may signal compromised oxygenation or increased work of breathing. Immediate focused assessment (oxygen saturation, use of accessory muscles, mental status) helps determine severity and guides next interventions.
B. Administer supplemental oxygen immediately: Oxygen may be needed, but it should follow a rapid assessment unless the patient is clearly unstable. Administering oxygen without assessment may mask the underlying cause of tachypnea.
C. Document the finding and notify the provider: Documentation and notification are important, but they are secondary to assessing the patient’s current respiratory status and identifying urgent signs of deterioration.
D. Encourage the patient to breathe deeply and slowly: This may be appropriate for anxiety-related tachypnea, but the cause of the increased respiratory rate must be assessed first to rule out hypoxia or acute respiratory compromise.
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