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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Assessment: Assessment involves collecting data about the client's condition. Noting the heart rate before administering medication is part of the assessment.
B. Analysis: Analysis involves interpreting the collected data to make decisions about the client's care. While the nurse is analyzing the data (the heart rate), this step follows the initial assessment.
C. Planning: Planning involves setting goals and deciding on interventions based on the assessment and analysis. Holding the medication could be considered part of planning but comes after assessing the heart rate.
D. Evaluation: Evaluation involves determining the effectiveness of interventions. This is not applicable in this situation.

A. "There are no provider's prescriptions available." B. "The client should be seen by a neurologist." C. "The client is disoriented. Pupils are slow to respond to light." D. "The client was found unconscious on the floor in her home."

Correct Answer is B

Explanation

A. "There are no provider's prescriptions available." This statement is about the current situation or background, not a recommendation.
B. "The client should be seen by a neurologist." The Recommendation (R) step involves suggesting actions or solutions, such as recommending that the client be seen by a neurologist.

C. "The client is disoriented. Pupils are slow to respond to light." This statement belongs in the Assessment (A) step as it describes the nurse’s clinical findings.
D. "The client was found unconscious on the floor in her home." This statement provides background information (B) about the client’s situation.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to administration of an antihypertensive medication, the nurse notes the client's heart rate is 50. The nurse then determines the blood pressure medication should be held. Which part of the nursing process is being fulfilled?

Correct Answer is A

Explanation

A nurse is planning to use the SBAR communication tool when giving on coming shift report. Which of the following statements should the nurse include in the R step?

Correct Answer is B

Explanation

A nurse is preparing a teaching plan to a client who is learning crutch walking. The nurse should identify the following actions as part of the planning step of the teaching plan.

The nurse is collaborating with the multidisciplinary team. Which of the following statements by the nurse indicates an understanding for interprofessional collaboration?

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Which patient below is best assigned to the LPN?

A nurse is completing discharge instructions. Which of the following barriers to learning should the nurse interpret as a need to postpone the teaching?

A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication?

A nurse is caring for a group of clients on a medical surgical unit. For which of the following care needs should the nurse initiate a referral for a speech therapist?

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