Pharmacology and the Nursing Process Test Bank Free

Correct Answer: A

Rationale: The correct answer is A: Identify factors interfering with goal achievement. This is the priority action because it focuses on understanding what caused the patient to fall despite the goal of preventing falls. By identifying the factors interfering with goal achievement, the nurse can make necessary adjustments to the care plan to prevent future falls. Choice B is incorrect because counseling the nursing assistive personnel and removing the fall risk sign does not address the root cause of the fall. Choice C is incorrect because shifting responsibility to the charge nurse for documentation does not address the immediate need to assess and address the factors contributing to the fall. Choice D is incorrect because documenting the fall is important but not the priority when the immediate concern is understanding why the fall occurred.

Correct Answer: B

Rationale: The correct answer is B because it encourages the patient to share any additional information they may have forgotten or overlooked, ensuring a thorough health history interview. Choice A is incorrect as it implies the interviewer is unprepared or disinterested. Choice C is inappropriate as it may make the patient feel guilty or inadequate. Choice D is incorrect as it does not address the possibility of gathering more relevant information from the patient.

Correct Answer: D

Rationale: The correct answer is D: Platelet count. Zidovudine (AZT) is known to cause bone marrow suppression, leading to decreased platelet production. Monitoring platelet count is crucial to detect early signs of thrombocytopenia, a common adverse effect of AZT. Rationale: A) RBC count: AZT can cause anemia, not specifically affecting the RBC count. B) Serum calcium: AZT does not typically affect calcium levels. C) Fasting blood glucose: AZT can cause hyperglycemia, but fasting blood glucose monitoring is not as critical as monitoring platelet count for AZT therapy.

Correct Answer: A

Rationale: The correct answer is A: Vision changes. Tamoxifen can cause serious ocular side effects like retinopathy and corneal changes. These adverse reactions can lead to vision impairment or loss, which is crucial to report immediately to prevent permanent damage. Headache (B), hearing loss (C), and anorexia (D) are not typically associated with tamoxifen use and do not pose immediate threats to the client's health compared to vision changes. It is important for the nurse to prioritize educating the client on recognizing and reporting vision changes promptly to ensure timely intervention and prevent irreversible consequences.

Correct Answer: A

Rationale: Rationale: Right-sided heart failure leads to fluid backup in the body causing dependent pitting edema due to fluid accumulation in the lower extremities. Orthopnea and exertional dyspnea are typically seen in left-sided heart failure. Hemoptysis is associated with conditions like pulmonary embolism or lung cancer, not right-sided heart failure. Therefore, the correct answer is A as it directly correlates with the symptoms of right-sided heart failure.