The nurse is preparing a teaching plan for a client who is learning how to care for their colostomy. The nurse should identify the following actions as part of the assessment step in the teaching plan.
The nurse determines the client’s readiness to learn
The nurse discusses types of food that the client needs to avoid
The nurse describes which supplies would be needed
Ask the client to demonstrate emptying of the colostomy bag
The Correct Answer is A
A. The nurse determines the client’s readiness to learn: Assessing the client's readiness to learn is part of the assessment phase of the teaching plan. It involves evaluating the client’s emotional and cognitive state to ensure they are prepared to absorb new information.
B. The nurse discusses types of food that the client needs to avoid: This is part of the teaching or implementation phase, not the assessment phase.
C. The nurse describes which supplies would be needed: Describing necessary supplies is also part of the teaching or implementation phase.
D. Ask the client to demonstrate emptying of the colostomy bag: This is part of the evaluation phase, where the nurse assesses the client’s ability to perform the task taught.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assessment: The Assessment section includes the nurse's findings and interpretations of the client's current condition. Information specific to sleep apnea would more likely be part of the client's history and not a direct assessment finding at this time.
B. Background: The Background section includes relevant background information that could impact the client’s current situation. This would be the appropriate section to include the client's history of sleep apnea.
C. Situation: The Situation section focuses on the current issue or reason for the communication. While it should be concise, it does not include detailed past medical history unless directly relevant to the current situation.
D. Recommendation: The Recommendation section is where the nurse suggests the next steps or interventions needed. Information about sleep apnea is not a recommendation but part of the client's background.
Correct Answer is C
Explanation
A. Vomiting: Vomiting is objective data because it can be observed and measured by the nurse.
B. Auscultation of heart murmur: This is objective data obtained through physical examination techniques.
C. Client's complaint of nausea: Subjective data is information reported by the client about their experience, feelings, or symptoms, which cannot be directly observed by others.
D. Blood pressure reading: This is objective data obtained through measurement.
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