A nurse is teaching a client to administer insulin. The nurse should identify the following actions as part of the assessment step of the teaching plan?
develop short term goal for the client in the teaching plan
Show the client how to draw up the insulin in a syringe
Assess the client’s readiness forming
Ask the client to demonstrate self-injection
The Correct Answer is C
A. Develop short-term goals for the client in the teaching plan: Developing goals is part of the planning phase, not the assessment phase.
B. Show the client how to draw up the insulin in a syringe: This is part of the implementation phase, where the nurse provides instructions and demonstrations.
C. Assess the client’s readiness for learning: Assessing the client’s readiness to learn is part of the assessment phase, determining if the client is prepared and willing to learn the new skill.
D. Ask the client to demonstrate self-injection: This is part of the evaluation phase, where the nurse assesses the client’s ability to perform the skill taught.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. “I am calling about Mrs. Smith’s recent development of dyspnea." This statement is part of the Situation (S) step, describing why the nurse is calling.
B. "The client is post-op day 1 following a lung resection." This statement provides Background (B) information, giving context about the patient’s medical history and recent events.
C. "Could you provide an order for an incentive spirometer?" This statement is part of the Recommendation (R) step, where the nurse suggests a specific action or order.
D. "The client's respirations are 24, even and bilateral. Afebrile." This statement is part of the Assessment (A) step, describing the current clinical findings or assessment of the patient’s condition.
Correct Answer is B
Explanation
A. Primary prevention: Primary prevention involves measures taken to prevent diseases or injuries before they occur, such as vaccinations or health education to prevent onset of illness. Teaching blood sugar monitoring to someone with diabetes is not primary prevention.
B. Tertiary prevention: Tertiary prevention involves managing disease post-diagnosis to slow or stop disease progression. Teaching a diabetic patient to monitor their blood sugar helps manage their existing condition and prevent complications, making it tertiary prevention.
C. Secondary prevention: Secondary prevention includes screening and early detection of disease to halt or slow its progress. Monitoring blood sugar levels in a diabetic patient is not about early detection but managing an existing condition.
D. Disease surveillance: Disease surveillance involves continuous, systematic collection, analysis, and interpretation of health data. This is not what the nurse is doing when teaching a client to monitor their blood sugar.
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