A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Moderate
Question Type: Multiple Choice (Clinical Judgment)
Question:
A nurse is preparing to administer a newly prescribed
medication. Before giving the first dose, the nurse reviews the
patient's allergies, current medications, recent laboratory
values, and vital signs. Which step of the Clinical Judgment
Measurement Model (CJMM) is the nurse performing?
A. Generate Solutions
B. Recognize Cues
C. Evaluate Outcomes
D. Take Action
Correct Answer: B. Recognize Cues
Rationale: Recognize Cues involves collecting and identifying
relevant patient information before making clinical decisions.
Reviewing assessment findings helps the nurse identify factors
that may influence medication safety.
Question 2
Difficulty: Moderate
,Question Type: Multiple Choice
Question:
A nurse notes that a patient receiving an antihypertensive
medication has a blood pressure of 84/52 mm Hg and reports
dizziness when standing. Which CJMM step requires the nurse
to determine the significance of these findings?
A. Analyze Cues
B. Take Action
C. Evaluate Outcomes
D. Recognize Cues
Correct Answer: A. Analyze Cues
Rationale: Analyze Cues involves interpreting assessment data
to determine what the findings mean. The nurse must
determine whether the symptoms are medication-related and
require intervention.
Question 3
Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
, A nurse is assessing a patient before administering insulin.
Which findings represent relevant cues that should be
recognized before giving the medication?
A. Current blood glucose level
B. Time of the patient's last meal
C. Hair color
D. Potassium level if available
E. Presence of symptoms of hypoglycemia
Correct Answer: A, B, D, E
Rationale: Blood glucose, meal timing, potassium level, and
symptoms of hypoglycemia directly affect insulin administration
and safety. Hair color has no clinical relevance.
Question 4
Difficulty: Difficult
Question Type: NGN Clinical Judgment
Question:
A patient is scheduled to receive an opioid analgesic.
Assessment findings include:
• Respiratory rate: 8 breaths/min
• Oxygen saturation: 91%