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 prepares to administer a newly prescribed medication.
Before giving the medication, the nurse notices the patient's
blood pressure is significantly lower than documented earlier.
Which action best demonstrates the Recognize Cues step of the
Clinical Judgment Management Model (CJMM)?
A. Holding the medication until contacting the provider
B. Comparing the current blood pressure with previous readings
C. Determining that the medication caused hypotension
D. Teaching the patient about possible adverse effects
Correct Answer: B
Rationale: Recognizing cues involves collecting and identifying
relevant assessment data. Comparing current and previous
blood pressure values identifies important clinical information
before further analysis or intervention.
Question 2
Difficulty: Moderate
Question Type: Select All That Apply (SATA)
,Question:
A nurse reviews assessment findings before administering an
antihypertensive medication. Which findings are considered
clinical cues that require further evaluation?
A. Blood pressure of 86/54 mm Hg
B. Patient reports dizziness upon standing
C. Medication label matches the prescription
D. Heart rate of 48 beats/minute
E. Patient ate breakfast
Correct Answer: A, B, D
Rationale: Hypotension, dizziness, and bradycardia are
significant cues that may affect medication safety. Matching the
medication label and eating breakfast are not priority clinical
cues requiring immediate analysis.
Question 3
Difficulty: Difficult
Question Type: NGN Clinical Judgment
Question:
A patient prescribed intravenous morphine becomes difficult to
awaken and has a respiratory rate of 8 breaths/minute.
Which nursing action best represents the Analyze Cues phase?
, A. Administer naloxone immediately
B. Conclude the patient is experiencing opioid-induced
respiratory depression based on assessment findings
C. Continue routine monitoring
D. Document the assessment findings
Correct Answer: B
Rationale: Analyzing cues requires interpreting assessment
findings to determine their significance. Recognizing opioid-
induced respiratory depression guides appropriate planning and
intervention.
Question 4
Difficulty: Moderate
Question Type: Multiple Choice
Question:
Which nursing action best demonstrates Prioritize Hypotheses
after assessing a patient receiving insulin?
A. Teaching proper insulin storage
B. Treating symptomatic hypoglycemia before documenting
care
C. Reviewing dietary recommendations
D. Scheduling a follow-up appointment