The nurse is checking the client’s blood sugar before administering insulin to a diabetic client. Which part of the nursing process is being fulfilled?
Evaluation.
Assessment.
Planning.
Implementation.
The Correct Answer is B
Choice A rationale
Evaluation is the phase of the nursing process where the nurse assesses the effectiveness of the interventions and determines whether the patient’s goals have been met. Checking blood sugar before administering insulin is not part of the evaluation phase.
Choice B rationale
Assessment is the phase of the nursing process where the nurse gathers information about the patient’s condition. Checking the client’s blood sugar before administering insulin is an assessment activity, as it involves collecting data to determine the patient’s current blood glucose level.
Choice C rationale
Planning is the phase of the nursing process where the nurse develops a plan of care based on the assessment data. Checking blood sugar is not part of the planning phase; it is an assessment activity.
Choice D rationale
Implementation is the phase of the nursing process where the nurse carries out the interventions outlined in the plan of care. While administering insulin is part of the implementation phase, checking blood sugar is an assessment activity that occurs before the implementation of the intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Tertiary prevention involves managing and rehabilitating patients with established diseases to prevent complications and improve quality of life. Referring a client to a specialist for further evaluation does not fit this category.
Choice B rationale
Primary prevention aims to prevent the onset of disease by reducing risk factors and promoting health. Referring a client to a specialist for further evaluation is not primary prevention.
Choice C rationale
Secondary prevention involves early detection and treatment of disease to prevent progression. Referring a client to a specialist for further evaluation fits this category as it aims to identify and address health issues early.
Choice D rationale
“Disease process” is not a recognized level of prevention. The correct levels are primary, secondary, and tertiary.
Correct Answer is D
Explanation
Choice A rationale
Calculating intake and output for the unit is a task that can be delegated to an LVN or UAP. It does not require the advanced clinical judgment and skills of an RN.
Choice B rationale
Inserting an NGT (nasogastric tube) for a client who is unable to eat is a task that can be performed by an LVN under the supervision of an RN. While it requires skill, it does not necessarily require the advanced clinical judgment of an RN.
Choice C rationale
Reinforcing teaching with a patient who is learning to walk with a quad cane can be done by an LVN or UAP. This task involves providing support and encouragement, but it does not require the advanced clinical judgment of an RN.
Choice D rationale
An unstable client complaining of feeling faint requires the advanced clinical judgment and skills of an RN. The RN is best equipped to assess the client’s condition, identify potential causes of instability, and implement appropriate interventions to stabilize the client.
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