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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Correct Answer is D
Explanation
Choice A rationale
Correcting the physician’s orders to match the chart is not within the nurse’s scope of practice. Nurses should not alter physician orders.
Choice B rationale
Ignoring the discrepancy is not appropriate. Nurses have a responsibility to ensure patient safety and accurate documentation.
Choice C rationale
Documenting the discrepancy but taking no further action does not address the potential risk to patient safety. Further action is necessary.
Choice D rationale
Documenting the discrepancy and notifying the physician is the correct course of action. This ensures that the physician is aware of the issue and can make any necessary corrections.
Correct Answer is B
Explanation
Choice A rationale
The client properly using a cane and demonstrating a steady gait indicates that the client has good mobility and balance. This is not likely to contribute to falls. Proper use of assistive devices like canes can actually help prevent falls by providing additional support and stability.
Choice B rationale
The client takes a sleeping pill. Many sleeping pills, especially those in the benzodiazepine class, can cause drowsiness, dizziness, and impaired coordination, which significantly increase the risk of falls. These medications can affect the central nervous system, leading to decreased alertness and slower reaction times, making it more likely for the client to fall.
Choice C rationale
The client uses a raised toilet seat. Raised toilet seats are designed to make it easier for individuals to sit down and stand up from the toilet, reducing the risk of falls in the bathroom. This adaptation is generally considered a fall prevention measure rather than a risk factor.
Choice D rationale
The client wears non-skid shoes. Non-skid shoes are designed to provide better traction and reduce the likelihood of slipping. Wearing such shoes is a preventive measure against falls, not a contributing factor.
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