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 C

Explanation

A. Vomiting: Vomiting is objective data because it can be observed and measured by the nurse.
B. Auscultation of heart murmur: This is objective data obtained through physical examination techniques.
C. Client's complaint of nausea: Subjective data is information reported by the client about their experience, feelings, or symptoms, which cannot be directly observed by others.
D. Blood pressure reading: This is objective data obtained through measurement.

A. Primary prevention B. Tertiary Prevention C. Secondary prevention D. Disease surveillance

Correct Answer is B

Explanation

A. Primary prevention: Primary prevention involves measures taken to prevent diseases or injuries before they occur, such as vaccinations or health education to prevent onset of illness. Teaching blood sugar monitoring to someone with diabetes is not primary prevention.
B. Tertiary prevention: Tertiary prevention involves managing disease post-diagnosis to slow or stop disease progression. Teaching a diabetic patient to monitor their blood sugar helps manage their existing condition and prevent complications, making it tertiary prevention.
C. Secondary prevention: Secondary prevention includes screening and early detection of disease to halt or slow its progress. Monitoring blood sugar levels in a diabetic patient is not about early detection but managing an existing condition.
D. Disease surveillance: Disease surveillance involves continuous, systematic collection, analysis, and interpretation of health data. This is not what the nurse is doing when teaching a client to monitor their blood sugar.

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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

During a health assessment, the nurse is collecting subjective data from the client. Which of the following is an example of subjective data?

Correct Answer is C

Explanation

A nurse at the clinic is teaching a client with diabetes the importance of monitoring their blood sugar. The nurse is implementing what level of preventative care?

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 teaching a client about a new medication. The nurse recognizes the following as a potential barrier to learning?

An RN has a critical client that needs constant monitoring. However, the RN also has other clients in need of care. Which tasks below could the RN delegate to the LPN to help continue the process of client care? Select three items

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

An RN has a critical client that needs constant monitoring. However, the RN also has other clients in need of care. Which tasks below could the RN delegate to the CNA to help continue the process of client care? (select all that apply) (3)

A client diagnosed with terminal cancer says to the nurse "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic?

A nurse on a medical surgical unit has received report on four clients. There is an LVN, RN, and UAP working. Which of the following clients would best to assign to the RN?

During an interaction with a client, the nurse notes the patient remains silent. What would be appropriate nurse responses for this interaction? (Select all that apply)