Pharmacology
A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Easy
Question Type: Multiple Choice (NCLEX-RN)
Question:
A nurse is caring for a client who reports itching and develops
widespread hives within minutes of receiving an intravenous
antibiotic. According to the Clinical Judgment Management
Model (CJMM), which action best represents the Recognize
Cues step?
A. Administer epinephrine as prescribed.
B. Document the client's allergy in the medical record.
C. Identify the hives, itching, and timing of symptom onset after
medication administration.
D. Determine that the client is experiencing an allergic reaction.
Correct Answer: C
Rationale:
Recognizing cues involves collecting and identifying relevant
assessment findings without interpreting them. Determining
that the reaction is allergic occurs during cue analysis.
Question 2
,Difficulty: Moderate
Question Type: Multiple Choice (NCLEX-RN)
Question:
A client receiving an opioid analgesic becomes difficult to
arouse, has a respiratory rate of 8 breaths/min, and oxygen
saturation of 86%. Which nursing action best reflects the
Prioritize Hypotheses phase?
A. Document the client's assessment findings.
B. Determine that opioid-induced respiratory depression is the
most urgent problem.
C. Administer naloxone immediately.
D. Notify the healthcare provider after completing the
assessment.
Correct Answer: B
Rationale:
Prioritizing hypotheses involves identifying the most urgent
clinical problem before implementing interventions.
Administration of naloxone occurs during the Take Action
phase.
Question 3
, Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
A nurse is preparing to administer digoxin. Which assessment
findings should be recognized as important cues before giving
the medication?
Select all that apply.
A. Apical pulse of 54 beats/min
B. Potassium level of 3.0 mEq/L
C. Blood pressure of 122/76 mm Hg
D. Reports of nausea and blurred vision
E. Heart rate increased after walking
Correct Answer: A, B, D
Rationale:
Bradycardia, hypokalemia, and symptoms suggestive of digoxin
toxicity require further evaluation before administration. The
remaining findings are not immediate concerns.
Question 4
Difficulty: Moderate
A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Easy
Question Type: Multiple Choice (NCLEX-RN)
Question:
A nurse is caring for a client who reports itching and develops
widespread hives within minutes of receiving an intravenous
antibiotic. According to the Clinical Judgment Management
Model (CJMM), which action best represents the Recognize
Cues step?
A. Administer epinephrine as prescribed.
B. Document the client's allergy in the medical record.
C. Identify the hives, itching, and timing of symptom onset after
medication administration.
D. Determine that the client is experiencing an allergic reaction.
Correct Answer: C
Rationale:
Recognizing cues involves collecting and identifying relevant
assessment findings without interpreting them. Determining
that the reaction is allergic occurs during cue analysis.
Question 2
,Difficulty: Moderate
Question Type: Multiple Choice (NCLEX-RN)
Question:
A client receiving an opioid analgesic becomes difficult to
arouse, has a respiratory rate of 8 breaths/min, and oxygen
saturation of 86%. Which nursing action best reflects the
Prioritize Hypotheses phase?
A. Document the client's assessment findings.
B. Determine that opioid-induced respiratory depression is the
most urgent problem.
C. Administer naloxone immediately.
D. Notify the healthcare provider after completing the
assessment.
Correct Answer: B
Rationale:
Prioritizing hypotheses involves identifying the most urgent
clinical problem before implementing interventions.
Administration of naloxone occurs during the Take Action
phase.
Question 3
, Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
A nurse is preparing to administer digoxin. Which assessment
findings should be recognized as important cues before giving
the medication?
Select all that apply.
A. Apical pulse of 54 beats/min
B. Potassium level of 3.0 mEq/L
C. Blood pressure of 122/76 mm Hg
D. Reports of nausea and blurred vision
E. Heart rate increased after walking
Correct Answer: A, B, D
Rationale:
Bradycardia, hypokalemia, and symptoms suggestive of digoxin
toxicity require further evaluation before administration. The
remaining findings are not immediate concerns.
Question 4
Difficulty: Moderate
