A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Moderate
Question Type: NGN Clinical Judgment (Case-Based)
Question:
A nurse is preparing to administer the first dose of an
intravenous antibiotic to a hospitalized patient with pneumonia.
Before administering the medication, the nurse reviews the
patient's history and notes a documented allergy to a
medication in the same drug class. The patient states, "I don't
remember exactly what happened, but I know they told me
never to take that medicine again."
Using the Clinical Judgment Measurement Model (CJMM),
which nursing action best demonstrates the Recognize Cues
(Assessment) step?
A. Notify the provider that the prescribed medication may not
be appropriate.
B. Review the patient's allergy history, medication record, and
previous reaction before administering the drug.
,C. Select an alternative antibiotic based on the patient's
diagnosis.
D. Evaluate whether the patient's respiratory status improves
after treatment.
Correct Answer: B
Rationale:
Recognize Cues focuses on gathering relevant assessment data
before making decisions. Reviewing the allergy history and
previous reaction provides essential information needed to
determine the safest course of action before medication
administration.
Question 2
Difficulty: Moderate
Question Type: Multiple Choice
Question:
A nurse reviews the following assessment findings before
administering a scheduled medication:
• Blood pressure: 84/50 mm Hg
• Heart rate: 52 beats/min
• Patient reports dizziness when sitting upright
, Which CJMM step is demonstrated when the nurse determines
these findings place the patient at increased risk for
medication-related complications?
A. Recognize Cues
B. Analyze Cues
C. Take Action
D. Evaluate Outcomes
Correct Answer: B
Rationale:
Analyze Cues involves interpreting collected assessment data to
determine its clinical significance. Identifying hypotension,
bradycardia, and dizziness as indicators of increased medication
risk represents analysis rather than data collection.
Question 3
Difficulty: Difficult
Question Type: Select All That Apply (SATA)
Question:
A nurse is caring for a patient receiving a newly prescribed
medication. Which nursing activities are examples of Recognize
Cues?