A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Moderate
Question Type: NGN Clinical Judgment (MCQ)
Question:
A nurse is caring for a patient who received the first dose of an
intravenous antibiotic. Five minutes after the infusion begins,
the patient reports itching and difficulty breathing. According to
the Clinical Judgment Measurement Model (CJMM), which
action best demonstrates Recognize Cues?
A. Stopping the infusion and notifying the provider
B. Identifying wheezing, facial swelling, and decreased oxygen
saturation
C. Administering intramuscular epinephrine
D. Determining the patient is experiencing an anaphylactic
reaction
Correct Answer: B
Rationale: Recognizing cues involves collecting and identifying
relevant assessment findings. Interpreting the findings as
anaphylaxis occurs during cue analysis.
,Question 2
Difficulty: Moderate
Question Type: Multiple Choice
Question:
A nurse reviews a patient's medication profile before
administering a newly prescribed medication. Which nursing
action best reflects the assessment phase of the nursing
process?
A. Evaluating whether the medication relieved symptoms
B. Identifying allergies, current medications, and vital signs
C. Teaching the patient about adverse effects
D. Documenting medication administration
Correct Answer: B
Rationale: Assessment includes gathering baseline information
needed for safe medication administration, including allergies,
medication history, and physical assessment.
Question 3
Difficulty: Difficult
Question Type: NGN Clinical Judgment (SATA)
, Question:
A patient receiving an opioid reports increasing drowsiness.
Respiratory rate decreases from 18 to 8 breaths/minute, oxygen
saturation falls to 88%, and the patient is difficult to arouse.
Which findings are cues that require immediate recognition?
Select all that apply.
A. Respiratory rate of 8 breaths/minute
B. Oxygen saturation of 88%
C. Patient sleeping after receiving pain medication
D. Difficulty awakening
E. Receiving an opioid medication
Correct Answer: A, B, D, E
Rationale: Severe respiratory depression, hypoxemia, difficulty
arousing, and opioid exposure are significant safety cues.
Sleeping alone after pain relief is expected and is not
necessarily concerning.
Question 4
Difficulty: Moderate
Question Type: Prioritization