Author Question: Which of the following abilities on the part of the client will the nurse evaluate based on the ... (Read 73 times)

bobbie · **on:** Jul 22, 2018

Which of the following abilities on the part of the client will the nurse evaluate based on the following outcome criterion determined by the nurse: Client will independently complete nec-essary assessments prior to administration of digoxin (

cardiotonic)? a. Assessing the respiratory rate
b. Palpating the radial pulse
c. Reviewing dietary habits
d. Inspecting colour of the skin

Question 2

The client has a nursing diagnosis of Impaired gas exchange as a result of excess secretions. An outcome for the client is that the airways will be free of secretions. A positive evaluation will focus on the client's:

a. Ability to perform incentive spirometry
b. Lungs clearing bilaterally on auscultation
c. Complaint of chest pain
d. Respiratory rate

lkanara2 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
The nurse should compare the established outcome criterion with the client's behaviour or re-sponse. In this case, the client is expected to independently complete the necessary assessments before administration of digoxin. The client should be able to palpate the radial pulse as an as-sessment before administration of digoxin.
The outcome criterion does not state anything about exercise. During evaluation, the nurse is to judge the degree of agreement between the outcome criterion and the client's behaviour.
The outcome criterion does not state anything about diet. Evaluating whether the client reviews his or her own dietary habits would not be comparable to a necessary assessment before medica-tion administration.
The outcome criterion does not state anything about the client's skin. The nurse, who knows that digoxin is a cardiotonic, understands that the client should be assessing his or her own heart rate.

Answer to Question 2

B
Auscultating lung sounds is the best way to determine whether airways are clear. A positive evaluation is that they are clear, as expected in the outcome statement.
The client's ability to perform incentive spirometry does not determine whether the client's air-ways are clear. It is an intervention that may help achieve clear airways.
A complaint of chest pain would be a negative outcome, and is not the focus for determining whether airways are free of secretions, as written in the outcome statement.
Respiratory rate may be an indicator of respiratory status, but it is not the best way to determine whether airways are free of secretions.