A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?

Establishing the priorities of client care

Reinforcing teaching about the client's diagnosis

Asking the client about the presence of pain

Comparing the client's current laboratory values to previous results

Answer and Explanation

The Correct Answer is B

A) Establishing the priorities of client care:

Establishing priorities of client care typically occurs during the planning phase of the nursing process, not during implementation. During the planning phase, the nurse identifies the most urgent client needs based on assessments and formulates a plan of action to address those needs.

B) Reinforcing teaching about the client's diagnosis:

Reinforcing teaching about the client's diagnosis is an appropriate activity during the implementation phase of the nursing process. Implementation involves carrying out the planned interventions, which may include educating the client about their diagnosis, treatment plan, and self-care strategies. Reinforcing teaching ensures that the client understands their condition and how to manage it effectively.

C) Asking the client about the presence of pain:

Assessing the client for pain is typically part of the assessment phase of the nursing process, not the implementation phase. During assessment, the nurse gathers data about the client's pain experience, including location, intensity, quality, and factors that alleviate or exacerbate pain.

D) Comparing the client's current laboratory values to previous results:

Comparing laboratory values is a component of data interpretation and analysis, which occurs primarily during the evaluation phase of the nursing process. While the nurse may review laboratory values during implementation to monitor the client's response to interventions, comparing current values to previous results is more closely associated with evaluating the effectiveness of care provided.

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Correct Answer is C

Explanation

A) Administer prescribed insulin:

Administering insulin is an essential aspect of managing type 1 diabetes mellitus, but before administering insulin, it's crucial to assess the client's current blood glucose level to determine the appropriate insulin dosage. Administering insulin without knowing the client's blood glucose level could lead to hypoglycemia if the blood glucose level is already low.

B) Check the calibration of the glucometer:

While it's important to ensure that the glucometer is calibrated correctly for accurate blood glucose readings, this step can be performed after obtaining the client's blood glucose level. Checking the calibration of the glucometer does not directly address the immediate need to assess the client's blood glucose level.

C) Obtain the client's capillary blood glucose level:

This is the most appropriate action to take first when providing morning care to a client with type 1 diabetes mellitus. Assessing the client's blood glucose level allows the nurse to determine the client's current glycemic status and make informed decisions about subsequent care, including insulin administration and breakfast provision.

D) Provide the client's breakfast:

Providing breakfast is an important aspect of morning care for a client with diabetes, but it should be done after assessing the client's blood glucose level. Depending on the client's blood glucose level, the nurse may need to adjust the timing or composition of the breakfast to ensure optimal glycemic control.

A. Assist in checking a unit of packed RBCS to administer to a client. B. Regulate the client's infusion pump after initiating a heparin drip infusion. C. Teach a client about hemodialysis. D. Create a plan of care for a client's discharge.

Correct Answer is ["A","B","C","D"]

Explanation

A) Assist in checking a unit of packed RBCS to administer to a client:

Assisting in checking a unit of packed red blood cells (RBCs) for transfusion is within the nurse's scope of practice. Nurses are responsible for verifying blood products before administration, ensuring compatibility, proper labeling, and appropriate handling to prevent transfusion reactions.

B) Regulate the client's infusion pump after initiating a heparin drip infusion:

Regulating the client's infusion pump after initiating a heparin drip infusion falls within the nurse's scope of practice. Nurses commonly administer and monitor intravenous medications, including heparin drips, and are responsible for regulating the infusion pump to deliver the medication at the prescribed rate.

C) Teach a client about hemodialysis:

Teaching a client about hemodialysis is within the nurse's scope of practice. Patient education is a fundamental aspect of nursing care, and nurses often provide information to clients and their families about various healthcare procedures, treatments, and self-care management, including hemodialysis.

D) Create a plan of care for a client's discharge:

Creating a plan of care for a client's discharge is within the nurse's scope of practice. Nurses are involved in discharge planning, which includes coordinating with the healthcare team, assessing the client's needs, providing education about post-discharge care, arranging follow-up appointments, and ensuring a smooth transition to the next level of care or home.

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A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has type 1 diabetes mellitus. Which of following actions should the nurse take first when providing morning care?

Correct Answer is C

Explanation

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Correct Answer is ["A","B","C","D"]

Explanation

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