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 reviews a patient's medication administration record
before giving a newly prescribed antibiotic. Which action best
demonstrates the Recognize Cues step of the Clinical Judgment
Measurement Model (CJMM)?
A. Administer the medication as prescribed.
B. Compare the patient's allergy history with the prescribed
antibiotic.
C. Determine the best time to administer the medication.
D. Evaluate whether the infection has resolved.
Correct Answer: B
Rationale: Recognizing cues involves collecting and identifying
relevant patient information before making clinical decisions.
Reviewing allergies before medication administration helps
identify potential safety risks.
Question 2
Difficulty: Moderate
Question Type: Multiple Choice (MCQ)
,Question:
A nurse notes that a patient prescribed an opioid has a
respiratory rate of 8 breaths/min and is difficult to arouse.
Which CJMM step is demonstrated when the nurse determines
that the opioid is the likely cause of the patient's condition?
A. Recognize Cues
B. Analyze Cues
C. Take Action
D. Evaluate Outcomes
Correct Answer: B
Rationale: Analyzing cues requires interpreting collected
assessment findings to identify likely causes of a patient's
condition. The nurse links the abnormal respiratory rate and
decreased consciousness to opioid effects.
Question 3
Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
A nurse is assessing a patient receiving intravenous furosemide.
Which findings are important cues to recognize before
administering the next dose?
, Select all that apply.
A. Blood pressure 88/54 mm Hg
B. Serum potassium 2.9 mEq/L
C. Lung sounds improved since yesterday
D. Daily weight decreased by 2 kg
E. Urine output during the previous shift
Correct Answer: A, B, D, E
Rationale: Blood pressure, potassium level, weight changes,
and urine output are essential assessment data before
administering a diuretic. Improved lung sounds are useful but
are less critical for determining immediate medication safety.
Question 4
Difficulty: Moderate
Question Type: Multiple Choice (MCQ)
Question:
A patient is prescribed insulin before breakfast. The nurse notes
that the patient's blood glucose is 62 mg/dL. Which action best
reflects the Prioritize Hypotheses step?
A. Immediately administer insulin.
B. Determine that hypoglycemia requires immediate attention
before insulin administration.