The nurse is preparing a teaching plan for a client who is learning to use the incentive spirometer. The nurse identifies the following action as part of the evaluation step in the teaching plan.

Assess the clients pain level

Ask the client to demonstrate use of the incentive spirometer

Develop a short-term goal for the client

Provide instructions on how to use the incentive spirometer

Answer and Explanation

The Correct Answer is B

A. Assess the client's pain level: Assessing the client's pain level is part of the assessment step, not the evaluation step.
B. Ask the client to demonstrate use of the incentive spirometer: Asking the client to demonstrate use of the incentive spirometer is a way to evaluate whether the client has understood and can perform the skill.
C. Develop a short-term goal for the client: Developing a short-term goal is part of the planning step, not the evaluation step.
D. Provide instructions on how to use the incentive spirometer: Providing instructions is part of the implementation step, not the evaluation step.

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Correct Answer is A

Explanation

A. The nurse encourages autonomy by allowing the client time to wash their face and upper chest with the left arm: The Self Care Model focuses on promoting independence and encouraging clients to do as much for themselves as possible. Allowing the client to perform tasks within their ability fosters autonomy and self-care.
B. The nurse performs range of motion exercises to the right arm: While beneficial, this does not directly promote the client's independence in self-care.
C. The nurse recognizes due to cultural preferences a female should provide the bed bath: This respects cultural preferences but does not relate directly to promoting self-care.
D. The nurse performs all the tasks: This does not encourage the client’s independence and is not aligned with the Self Care Model.

A. Right Task B. Right communication C. Right supervision D. Right circumstance

Correct Answer is C

Explanation

A. Right Task: The right task refers to ensuring the task is appropriate to delegate. This situation is more about monitoring the task.
B. Right Communication: The right communication involves clear, concise instructions. This scenario involves oversight rather than instruction.
C. Right Supervision: Right supervision involves monitoring the task and providing guidance and feedback. Observing the UAP and ensuring the correct cuff size is being used demonstrates appropriate supervision.
D. Right Circumstance: The right circumstance refers to ensuring the client’s condition is appropriate for delegation. This situation is about supervising the task.

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The nurse is preparing a teaching plan for a client who is learning to use the incentive spirometer. The nurse identifies the following action as part of the evaluation step in the teaching plan.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing morning care to a client with right arm hemiparesis. Which nursing action demonstrates use of the Self Care Model when planning care?

Correct Answer is A

Explanation

A nurse delegates to an assistive personnel. During the delegation the nurse observes the UAP using the large cuff on a client who is overweight. The nurse is demonstrating which of the following rights of delegation?

Correct Answer is C

Explanation

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