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 D
Explanation
Choice A rationale
The client speaking another language is an important factor to consider, but it is not the most comprehensive factor. Language barriers can affect communication and understanding, but they can be addressed with interpreters and translation services. Considering the client’s culture encompasses language and other cultural aspects that influence healthcare.
Choice B rationale
The client having decreased vision but wearing glasses is a specific factor related to sensory perception. While it is important to consider, it does not encompass the broader cultural context that can impact healthcare. Addressing vision issues is part of a comprehensive assessment, but culture provides a more holistic understanding.
Choice C rationale
The client having hearing loss but functioning hearing aids is another specific factor related to sensory perception. It is important to consider for effective communication, but it does not provide a comprehensive understanding of the client’s cultural background and its impact on healthcare.
Choice D rationale
The client’s culture is the most comprehensive factor to consider. Culture influences health beliefs, practices, communication styles, and decision-making. Understanding the client’s cultural background helps the nurse provide culturally competent care, build trust, and address any potential cultural barriers to healthcare.
Correct Answer is B
Explanation
Choice A rationale
Asking for an order for an incentive spirometer is a recommendation, which belongs in the R step of SBAR. The B step should provide background information about the patient’s condition.
Choice B rationale
Providing the client’s history of sleep apnea is appropriate for the B step, which involves giving background information relevant to the current situation.
Choice C rationale
Describing the client’s current respirations and temperature is part of the Assessment step, not the Background step. The B step should focus on the patient’s medical history and relevant background information.
Choice D rationale
Stating that the client was found unconscious on the floor is part of the Situation step, not the Background step. The B step should provide background information about the patient’s condition.
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