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. Give the client his blood pressure medication: Administering medications is outside the scope of practice for UAPs and should be done by licensed nursing staff.
B. Measure the vital signs: Measuring vital signs is within the scope of practice for UAPs and can be safely assigned to them.
C. Report any unusual lung sounds: Assessing and interpreting lung sounds require the skills and training of a licensed nurse.
D. Teach the patient about a heart-healthy diet: Teaching requires assessment and evaluation, which are within the RN’s scope of practice, not the UAP’s.
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.
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