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 is reviewing a newly prescribed medication before
administration. Which action best demonstrates the Recognize
Cues step of the Clinical Judgment Measurement Model
(CJMM)?
• Identifying that the patient has a documented allergy to
the medication
• Determining that the medication dose should be reduced
• Administering the medication with food
• Evaluating whether the medication relieved symptoms
Correct Answer: A
Rationale: Recognizing cues involves collecting relevant
assessment data such as allergies, vital signs, laboratory results,
and medication history before making clinical decisions.
Question 2
Difficulty: Moderate
Question Type: Multiple Choice
Question:
,A patient receiving Warfarin has an INR of 5.2 and reports
bleeding gums. Which CJMM step is the nurse performing when
identifying that the patient is at increased risk for hemorrhage?
• Recognize Cues
• Analyze Cues
• Take Action
• Evaluate Outcomes
Correct Answer: B
Rationale: Analyze Cues requires interpreting assessment
findings and determining their clinical significance. The elevated
INR and bleeding indicate a high risk for hemorrhage.
Question 3
Difficulty: Moderate
Question Type: Prioritization
Question:
A nurse is caring for four patients receiving medications. Which
patient should the nurse assess first?
• A patient receiving Lisinopril who reports a mild dry cough
• A patient receiving Metformin who reports decreased
appetite
, • A patient receiving Morphine who has a respiratory rate of
8/min
• A patient receiving Furosemide who needs assistance to
the bathroom
Correct Answer: C
Rationale: Prioritizing hypotheses focuses on identifying the
most urgent problem. Respiratory depression from morphine is
immediately life-threatening and requires prompt assessment
and intervention.
Question 4
Difficulty: Moderate
Question Type: Multiple Choice
Question:
Which nursing action represents the Generate Solutions step of
the nursing process?
• Documenting the patient's blood pressure
• Determining that a patient may be experiencing
medication toxicity
• Planning to administer an antidote and notify the provider
• Reassessing the patient after treatment
Correct Answer: C