A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Easy
Question Type: Multiple Choice
Question:
A nurse prepares to administer a newly prescribed medication.
Before giving the medication, the nurse reviews the patient's
allergies, laboratory values, and current medications. Which
step of the Clinical Judgment Measurement Model (CJMM) is
the nurse demonstrating?
A. Generate Solutions
B. Recognize Cues
C. Evaluate Outcomes
D. Take Action
Correct Answer: B. Recognize Cues
Rationale: Recognize Cues involves collecting and identifying
relevant patient information before making clinical decisions.
Reviewing allergies, laboratory values, and medication history
helps identify potential safety concerns before medication
administration.
Question 2
,Difficulty: Easy
Question Type: Multiple Choice
Question:
A patient prescribed an antihypertensive medication reports
dizziness when standing. Which nursing action best reflects the
Analyze Cues phase?
A. Document the patient's symptoms after discharge.
B. Determine whether the dizziness may be related to
orthostatic hypotension.
C. Administer the medication immediately.
D. Teach the patient about healthy eating.
Correct Answer: B. Determine whether the dizziness may be
related to orthostatic hypotension.
Rationale: Analyze Cues requires interpreting assessment
findings and connecting symptoms with possible clinical causes.
The nurse considers whether the medication may be producing
an adverse effect.
Question 3
Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
, A nurse prepares to administer a high-alert medication. Which
actions demonstrate safe medication administration? (Select all
that apply.)
A. Verify the patient's identity using two identifiers.
B. Review allergies before administration.
C. Skip patient education if the medication is routine.
D. Confirm the prescribed dose.
E. Assess for contraindications.
Correct Answer: A, B, D, E
Rationale: Safe medication administration includes verifying
identity, confirming allergies, validating the prescribed dose,
and assessing for contraindications. Even routine medications
require appropriate patient education.
Question 4
Difficulty: Moderate
Question Type: NGN Clinical Judgment
Question:
A patient is prescribed the first dose of an opioid analgesic after
surgery. Respiratory rate is 10 breaths/minute, oxygen
saturation is 91%, and the patient is difficult to awaken.
What is the nurse's priority action?