The nurse asks a client if they have any allergies to medication. Which part of the nursing process is the nurse utilizing?
Assessment
Implementation
Planning
Diagnosis
The Correct Answer is A
A. Assessment: Asking about medication allergies is part of the data-gathering phase of the nursing process. This step involves collecting subjective and objective information to identify factors that may affect pharmacologic safety, including hypersensitivity reactions or previous adverse responses that could contraindicate medication therapy.
B. Implementation: Implementation refers to carrying out interventions such as administering medications or providing teaching. Since the nurse is gathering information rather than performing an intervention, this phase is not being used.
C. Planning: Planning involves developing goals and selecting interventions based on assessment data. The nurse cannot begin planning until allergy information and other relevant data have already been collected, so this step does not apply.
D. Diagnosis: Nursing diagnosis involves analyzing assessment data to identify client problems or risks. Asking about allergies occurs before this analytical step and therefore belongs to the assessment phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ileus: Octreotide can significantly slow gastrointestinal motility by inhibiting the secretion of gastrointestinal hormones and reducing peristalsis. Development of an ileus is a serious complication because it can lead to bowel obstruction, abdominal distention, pain, and potential ischemia, requiring immediate medical evaluation.
B. Sinusitis: While sinusitis can occur as a nonspecific side effect, it is generally mild and not life-threatening. It does not directly relate to the pharmacologic effects of octreotide on the gastrointestinal or endocrine systems.
C. Vomiting: Vomiting is a known but less severe gastrointestinal side effect of octreotide. Although uncomfortable, it is usually self-limiting and can be managed with supportive care or dose adjustment, unlike an ileus.
D. Headache: Headaches are a common and generally mild adverse effect associated with octreotide. They are typically transient and do not indicate a serious pharmacologic complication or systemic risk requiring immediate intervention.
Correct Answer is C
Explanation
A. Pharmacy location: The location of the pharmacy may affect access to medication but does not physiologically influence how a drug works in the body. It does not alter absorption, metabolism, distribution, or excretion of the medication.
B. Client's financial status: Financial status may impact adherence if the client cannot afford the medication, but it does not directly affect the pharmacologic response once the drug is administered.
C. Client's diet: Diet can significantly influence drug response. Foods may interact with drug absorption (e.g., calcium with tetracyclines), metabolism (e.g., grapefruit juice inhibiting CYP3A4), or excretion, thereby altering the effectiveness and safety of the medication.
D. Type of insurance: Insurance affects access to medications and cost coverage but does not change the pharmacokinetics or pharmacodynamics of a drug, so it does not directly affect therapeutic response.
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