Process
10th Edition
• Author(s)Linda Lane Lilley;
Shelly Rainforth Collins; Julie
S. Snyder
,TEST BANK
Question 1 — MCQ
Clinical Scenario
A nurse is preparing to administer a newly prescribed
antihypertensive medication to a hospitalized adult patient.
Before giving the medication, the nurse reviews the patient's
blood pressure, heart rate, allergy history, and current
medications.
Question Stem
Which step of the nursing process is primarily being
demonstrated?
Answer Options
A. Planning
B. Assessment
C. Evaluation
D. Nursing Diagnosis
Correct Answer
B. Assessment
,Comprehensive Rationale
Assessment is the systematic collection of patient data before
clinical decisions are made. Reviewing vital signs, allergies, and
current medications helps identify factors that may affect
medication safety and effectiveness.
Medication administration begins with thorough assessment
because pharmacologic responses vary based on physiologic
status, comorbidities, and concurrent therapies.
The nurse is gathering information needed to determine
whether the medication should be administered safely.
Distractor Analysis
A. Planning
• Incorrect because planning occurs after assessment.
• Misconception: Nurses sometimes assume preparing to
give a medication equals planning.
• Safety Risk: Omitting assessment may lead to adverse drug
events.
• Appropriate Action: Complete assessment before planning
interventions.
C. Evaluation
, • Evaluation occurs after medication administration.
• Misconception: Checking effectiveness before giving
medication.
• Safety Risk: Inaccurate interpretation of therapeutic
response.
D. Nursing Diagnosis
• Diagnosis follows assessment and identifies patient
responses.
• Safety Risk: Clinical decisions based on incomplete data.
Nursing Process Integration
Primary Component: Assessment
Remaining Steps:
• Diagnosis: Identify medication-related problems.
• Planning: Establish therapeutic goals.
• Implementation: Administer medication safely.
• Evaluation: Assess outcomes and adverse effects.
NCJMM Competencies
✓ Recognize Cues