Process
10th Edition
• Author(s)Linda Lane Lilley;
Shelly Rainforth Collins; Julie
S. Snyder
TEST BANK
1) MCQ
,Question Type: Multiple-Choice Question
Clinical Scenario:
A nurse is preparing to administer the morning medications to a
78-year-old client admitted with heart failure and hypertension.
Question Stem:
Which nursing action is the priority before administering any
prescribed medication?
Answer Options:
A. Review the medication’s trade and generic names
B. Compare the client’s current condition with expected
therapeutic effects
C. Ask the client to state their favorite time to take medications
D. Document the medication administration after giving the
dose
Correct Answer:
B. Compare the client’s current condition with expected
therapeutic effects
Detailed Rationale:
Assessment is the first step in the nursing process and must
precede medication administration. The nurse must determine
whether it is safe and appropriate to give the medication by
comparing current assessment data with expected therapeutic
effects and known contraindications. This is especially
,important in older adults, who are at higher risk for adverse
drug reactions and polypharmacy-related problems.
Incorrect Option Analysis:
• A: Knowing the trade and generic names is important for
safety, but it does not come before assessing the client’s
status.
• C: Client preference may support adherence, but it is not
the priority safety step.
• D: Documentation is necessary, but only after the
medication has been administered and the client has been
assessed.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies: Recognize Cues, Analyze Cues
Difficulty Level: Easy
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Pharmacological and Parenteral
Therapies
Medication Safety Focus: Assessment before administration;
age-related risk
Key Learning Objective: Identify assessment as the first priority
before medication administration.
2) MCQ
, Question Type: Multiple-Choice Question
Clinical Scenario:
A client taking oral furosemide asks why the nurse checks their
blood pressure and weight every morning.
Question Stem:
Which explanation by the nurse is best?
Answer Options:
A. “These checks help confirm that the medication is being
absorbed correctly.”
B. “These checks help determine whether the medication is
producing the intended effect.”
C. “These checks are only needed if the client reports dizziness.”
D. “These checks replace the need for follow-up laboratory
testing.”
Correct Answer:
B. “These checks help determine whether the medication is
producing the intended effect.”
Detailed Rationale:
Evaluation of therapeutic effectiveness is a core part of the
nursing process. Furosemide is expected to reduce fluid volume,
which can be evaluated through daily weight, blood pressure,
edema, and urine output. The nurse uses these data to
determine whether the prescribed drug therapy is achieving the
desired outcome.