A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Easy
Question Type: Multiple Choice (Clinical Judgment)
Question:
A nurse is preparing to administer a newly prescribed
antihypertensive medication. Before giving the medication, the
nurse reviews the client's blood pressure, heart rate, allergies,
and current medications. Which step of the Clinical Judgment
Measurement Model (CJMM) is the nurse demonstrating?
A. Analyze cues
B. Recognize cues
C. Generate solutions
D. Evaluate outcomes
Correct Answer: B. Recognize cues
Rationale: Recognizing cues involves collecting and reviewing
relevant assessment data before making clinical decisions. This
includes vital signs, allergies, medication history, and laboratory
results.
,Question 2
Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
A nurse is assessing a client before administering intravenous
morphine. Which findings should the nurse recognize as
important cues requiring further evaluation?
A. Respiratory rate of 10 breaths/minute
B. Pain score of 8/10
C. Oxygen saturation of 89%
D. History of opioid allergy
E. Blood glucose of 102 mg/dL
Correct Answer: A, C, D
Rationale: A low respiratory rate, hypoxemia, and a
documented opioid allergy are significant safety concerns
before opioid administration. Severe pain supports the
indication for treatment but does not override safety risks.
Question 3
Difficulty: Moderate
Question Type: Multiple Choice
, Question:
After reviewing assessment findings, a nurse concludes that a
client receiving insulin is experiencing hypoglycemia rather than
medication toxicity. Which CJMM step is being applied?
A. Recognize cues
B. Analyze cues
C. Take action
D. Evaluate outcomes
Correct Answer: B. Analyze cues
Rationale: Analyzing cues involves interpreting collected
information to determine the most likely clinical problem or
hypothesis before planning interventions.
Question 4
Difficulty: Moderate
Question Type: NGN Case-Based
Question:
A client is prescribed the first dose of an oral antibiotic.
Assessment findings:
• Temperature: 39.1°C (102.4°F)
• WBC: 16,500/mm³