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: A

Rationale: The correct answer is A, below 70mg/dl, for a hypoglycemic client. Hypoglycemia is defined as low blood glucose levels, typically below 70mg/dl. Symptoms of hypoglycemia include confusion, sweating, shakiness, and palpitations. Treating hypoglycemia involves providing the client with a fast-acting source of glucose to raise their blood sugar levels quickly. Choices B, C, and D are incorrect as they indicate normal or elevated blood glucose levels, which are not characteristic of hypoglycemia. It is crucial for the nurse to recognize and promptly address hypoglycemia to prevent potential complications.

Correct Answer: B

Rationale: The correct answer is B: Basilic vein. It is preferred for IV therapy due to its size, accessibility, and lower risk of complications. Basilic vein is deep and stable, aiding in successful catheter insertion and reduced risk of infiltration. Jugular vein (A) is not typically used due to the high risk of complications like infection. Brachiocephalic (C) and Axillary (D) veins are less commonly used as they are smaller and more prone to complications compared to the Basilic vein. In summary, the Basilic vein is the optimal choice for initiating IV therapy due to its size, accessibility, stability, and lower risk of complications.

Correct Answer: A

Rationale: Correct Answer: A - Apply immobilization device after examination by physician Rationale: 1. Immobilization helps reduce pain and prevent further injury. 2. Physician examination ensures proper diagnosis and treatment plan. 3. Immobilization device may include chest binders or splints for support. 4. It is crucial to follow medical advice to prevent complications. Summary: B: Discouraging deep breaths can lead to respiratory complications. C: Advising against analgesics can increase pain and hinder recovery. D: Increased fluid intake is important but not directly related to rib fracture care.

Correct Answer: D

Rationale: The correct answer is D because morphine helps in acute pulmonary edema by decreasing peripheral resistance, pulmonary capillary pressure, and transudation of fluid. Morphine causes vasodilation, reducing peripheral resistance, which helps redistribute blood flow to the periphery. It also reduces pulmonary capillary pressure by decreasing preload and afterload, leading to decreased fluid transudation into the alveoli. Choices A, B, and C individually do not cover all the effects of morphine in acute pulmonary edema, making them incorrect.