A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Easy
Question Type: Multiple Choice (MCQ)
Question:
A nurse is preparing to administer a newly prescribed
medication. Before giving the medication, the nurse reviews the
patient's allergies, recent laboratory results, and current
assessment findings. Which step of the Clinical Judgment
Measurement Model (CJMM) is the nurse performing?
A. Generate Solutions
B. Recognize Cues
C. Take Action
D. Evaluate Outcomes
Correct Answer: B. Recognize Cues
Rationale: Recognizing cues involves collecting and identifying
relevant assessment information, including allergies, laboratory
values, and clinical findings. This information guides safe
medication administration.
Question 2
,Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
A nurse is assessing a patient before administering an
antihypertensive medication. Which findings are important cues
to recognize before giving the medication? (Select all that
apply.)
A. Blood pressure of 88/54 mm Hg
B. Heart rate of 52 beats/minute
C. Patient reports dizziness when standing
D. Favorite television program
E. Serum potassium level
Correct Answer: A, B, C, E
Rationale: Hypotension, bradycardia, orthostatic dizziness, and
electrolyte values may affect medication safety. The patient's
television preference is unrelated to medication administration.
Question 3
Difficulty: Moderate
Question Type: NGN Clinical Judgment
Question:
, A patient receiving intravenous antibiotics develops itching,
facial swelling, wheezing, and hypotension within minutes of
the infusion beginning.
Which action should the nurse prioritize?
A. Continue the infusion and reassess in 15 minutes.
B. Slow the infusion rate.
C. Stop the infusion and initiate emergency interventions.
D. Document the findings before intervening.
Correct Answer: C. Stop the infusion and initiate emergency
interventions.
Rationale: The patient demonstrates signs of an acute allergic
reaction requiring immediate intervention. Medication
administration should stop while emergency treatment is
initiated.
Question 4
Difficulty: Moderate
Question Type: Multiple Choice (Prioritization)
Question:
A nurse identifies the following assessment findings before
medication administration:
• Temperature 38.8°C (101.8°F)