Chapter01:TheNursingProcessandDrugTherapy
Lilley:PharmacologyandtheNursingProcess,10thEdition
s
MULTIPLECHOICE
1. Thenurseisdevelopingahumanneedsstatementforapatientwhohasanewdiagnosisofheart
s failure.Identificationofhumanneedsstatementsoccurwithwhichoftheseactivities?
a. Collectionofpatientdata
b. Administeringinterventions
c. Decidingonpatientoutcomes
d. Documentingthepatient‘sbehavior
ANS:A s
Identificationofhumanneedsoccurswiththecollectionofpatientdata.
DIF: CognitiveLevel:Understanding(Comprehension)
TOP: NursingProcess:HumanNeedsStatement
s s
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
s
2. Thepatientistoreceiveoralguaifenesintwiceaday.Today,thenursewasbusyandgavethe
medication2hoursafterthescheduleddosewasdue.Whattypeofproblemdoesthisrepresent?
s
a. ―Righttime‖
b. ―Rightdose‖
c. ―Rightroute‖
d. ―Rightmedication‖
ANS:A s
―Righttime‖iscorrectbecausethemedicationwasgivenmorethan30minutesafterthescheduled
dosewasdue.―Dose‖isincorrectbecausethedoseisnotrelatedtothetimethemedication
s
administrationisscheduled.―Route‖isincorrectbecausetherouteisnotaffected.
s
―Medication‖isincorrectbecausethemedicationorderedwillnotchange.
DIF: CognitiveLevel:Applying(Application)
TOP: NursingProcess:Implementation
s s
MSC: NCLEX:SafeandEffectiveCareEnvironment:SafetyandInfectionControl
s
3. Thenursehasbeenmonitoringthepatient‘sprogressonanewdrugregimensincethefirstdose
sanddocumentingthepatient‘stherapeuticresponsetothemedication.Whichphaseofthe
nursingprocessdotheseactionsillustrate?
s
a. Humanneedsstatement
b. Planning
c. Implementation
d. Evaluation
ANS:D s
Monitoring the patient‘s progress, including the patient‘s response to the medication, is part of the
s s s s s s s s s s s s s s
evaluation phase. Planning, implementation, and human needs statement are not illustrated bythis
s s s s s s s s s s s s
example.
s
DIF: CognitiveLevel:Understanding(Comprehension)
s TOP: NursingProcess:Evaluation
s
PRIMEXAM.COM
, MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
s
4. Thenurseisassignedtoapatientwhoisnewlydiagnosedwithtype1diabetesmellitus.
Whichstatementbestillustratesanoutcomecriterionforthispatient?
s
a.Thepatientwillfollowinstructions.
b.Thepatientwillnotexperiencecomplications.
c.Thepatientwilladheretothenewinsulintreatmentregimen.
d.Thepatientwilldemonstratecorrectbloodglucosetestingtechnique.
ANS:D s
―Demonstratingcorrectbloodglucosetestingtechnique‖isaspecificandmeasurableoutcome
criterion.―Followinginstructions‖and―notexperiencingcomplications‖arenotspecificcriteria.
s
―Adheringtonewregimen‖wouldbedifficulttomeasure.
DIF: CognitiveLevel:Applying(Application) TOP:NursingProcess:Planning
s
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
s s
5. Whichactivitybestreflectstheimplementationphaseofthenursingprocessforthepatientwhois
newlydiagnosedwithhypertension?
s
a. Providingeducationonkeepingajournalofbloodpressurereadings
b. Settinggoalsandoutcomecriteriawiththepatient‘sinput
c. Recordingadrughistoryregardingover-the-countermedicationsusedathome
d. Formulatinghumanneedsstatementsregardingdeficientknowledgerelatedtothenew
treatmentregimen
s
ANS:A s
Educationisaninterventionthatoccursduringtheimplementationphase.Settinggoalsandoutcomes
reflectstheplanningphase.Recordingadrughistoryreflectstheassessmentphase.Formulatinghuman
s
needsstatementsreflectsanalysisofdataaspartofplanning.
s
DIF: CognitiveLevel:Applying(Application)
TOP: NursingProcess:Implementation
s s
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
s
6. Themedicationorderreads,―Giveondansetron4mg,30minutesbeforebeginning
schemotherapytopreventnausea.‖Thenursenotesthattherouteismissingfromtheorder.What
isthenurse‘sbestaction?
s
a. Givethemedicationintravenouslybecausethepatientmightvomit.
b. Givethemedicationorallybecausethetabletsareavailablein4-mgdoses.
c. Contacttheprescribertoclarifytherouteofthemedicationordered.
d. Holdthemedicationuntiltheprescriberreturnstomakerounds.
ANS:C s
Acompletemedicationorderincludestherouteofadministration.Ifamedicationorderdoesnot
includetheroute,thenursemustasktheprescribertoclarifyit.Theintravenousandoralroutesare
s
notinterchangeable.Holdingthemedicationuntiltheprescriberreturnswouldmeanthatthe
s
spatientwouldnotreceiveaneededmedication.
DIF: CognitiveLevel:Applying(Application)
TOP: NursingProcess:Implementation
s s
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
s
PRIMEXAM.COM
, 7. Whenthenurseconsidersthetimingofadrugdose,whichfactorisappropriatetoconsiderwhen
decidingwhentogiveadrug?
s
a. Thepatient‘sabilitytoswallow
b. Thepatient‘sheight
c. Thepatient‘slastmeal
d. Thepatient‘sallergies
ANS:C s
Thenursemust consider specific pharmacokinetic/pharmacodynamic drugpropertiesthat may be
s s s s s s
affected by the timingofthelastmeal. Thepatient‘sability to swallow, height, andallergies arenot
s s s s s s s s s s
factorstoconsiderregardingthetimingofthedrug‘sadministration.
s
DIF: CognitiveLevel:Understanding(Comprehension)
TOP: NursingProcess:Assessment
s s
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
s
8. Thenurseisperforminganassessmentofanewlyadmittedpatient.Whichisanexampleof
subjectivedata?
s
a. Weight155pounds
b. Pulse72beats/minute
c. Thepatientreportsthatheusestheherbalproductginkgo
d. Thepatient‘scompletebloodcountresults
ANS:C s
Subjectivedataincludeinformationsharedthroughthespokenwordbyanyreliablesource,suchas
thepatient.Objectivedatamaybedefinedasanyinformationgatheredthroughthesensesorthat
s
swhichisseen,heard,felt,orsmelled.Apatient‘spulse,weight,andlaboratorytestsareallexamples
ofobjectivedata.
s
DIF: CognitiveLevel:Understanding(Comprehension)
TOP: NursingProcess:Assessment
s s
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
s
MULTIPLERESPONSE
1. Whengivingmedications,thenursewillfollowtherightsofmedicationadministration.Therights
include the right documentation, the right reason, the right response, and the patient‘s right to
s s s s s s s s s s s s s s s
refuse.Whichoftheseareadditionalrights?(Selectallthatapply.)
s
a. Rightdrug
b. Rightroute
c. Rightdose
d. Rightdiagnosis
e. Righttime
f. Rightpatient
ANS:A,B,C,E,F s
Additionalrightsofmedicationadministrationmustalwaysincludetherightdrug,rightdose,right
time,rightroute,andrightpatient.Therightdiagnosisisincorrect.
s
DIF: CognitiveLevel:Remembering (Knowledge) b
TOP: NursingProcess:Implementation
s s
PRIMEXAM.COM
, MSC: NCLEX:SafeandEffectiveCareEnvironment:SafetyandInfectionControl
s
OTHER
1. Placethephasesofthenursingprocessinthecorrectorder,with1asthefirstphaseand5asthelast
phase.
s
a. Planning
b. Evaluation
c. Assessment
d. Implementation
e. Humanneedsstatement
ANS:
C,E,A,D,B
Thenursingprocessisanongoingprocessthatbeginswithassessingandcontinueswithhuman
needsstatement,planning,implementing,andevaluating.
s
DIF: CognitiveLevel:Applying(Application) TOP:NursingProcess:General
s
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
s s
PRIMEXAM.COM
Lilley:PharmacologyandtheNursingProcess,10thEdition
s
MULTIPLECHOICE
1. Thenurseisdevelopingahumanneedsstatementforapatientwhohasanewdiagnosisofheart
s failure.Identificationofhumanneedsstatementsoccurwithwhichoftheseactivities?
a. Collectionofpatientdata
b. Administeringinterventions
c. Decidingonpatientoutcomes
d. Documentingthepatient‘sbehavior
ANS:A s
Identificationofhumanneedsoccurswiththecollectionofpatientdata.
DIF: CognitiveLevel:Understanding(Comprehension)
TOP: NursingProcess:HumanNeedsStatement
s s
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
s
2. Thepatientistoreceiveoralguaifenesintwiceaday.Today,thenursewasbusyandgavethe
medication2hoursafterthescheduleddosewasdue.Whattypeofproblemdoesthisrepresent?
s
a. ―Righttime‖
b. ―Rightdose‖
c. ―Rightroute‖
d. ―Rightmedication‖
ANS:A s
―Righttime‖iscorrectbecausethemedicationwasgivenmorethan30minutesafterthescheduled
dosewasdue.―Dose‖isincorrectbecausethedoseisnotrelatedtothetimethemedication
s
administrationisscheduled.―Route‖isincorrectbecausetherouteisnotaffected.
s
―Medication‖isincorrectbecausethemedicationorderedwillnotchange.
DIF: CognitiveLevel:Applying(Application)
TOP: NursingProcess:Implementation
s s
MSC: NCLEX:SafeandEffectiveCareEnvironment:SafetyandInfectionControl
s
3. Thenursehasbeenmonitoringthepatient‘sprogressonanewdrugregimensincethefirstdose
sanddocumentingthepatient‘stherapeuticresponsetothemedication.Whichphaseofthe
nursingprocessdotheseactionsillustrate?
s
a. Humanneedsstatement
b. Planning
c. Implementation
d. Evaluation
ANS:D s
Monitoring the patient‘s progress, including the patient‘s response to the medication, is part of the
s s s s s s s s s s s s s s
evaluation phase. Planning, implementation, and human needs statement are not illustrated bythis
s s s s s s s s s s s s
example.
s
DIF: CognitiveLevel:Understanding(Comprehension)
s TOP: NursingProcess:Evaluation
s
PRIMEXAM.COM
, MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
s
4. Thenurseisassignedtoapatientwhoisnewlydiagnosedwithtype1diabetesmellitus.
Whichstatementbestillustratesanoutcomecriterionforthispatient?
s
a.Thepatientwillfollowinstructions.
b.Thepatientwillnotexperiencecomplications.
c.Thepatientwilladheretothenewinsulintreatmentregimen.
d.Thepatientwilldemonstratecorrectbloodglucosetestingtechnique.
ANS:D s
―Demonstratingcorrectbloodglucosetestingtechnique‖isaspecificandmeasurableoutcome
criterion.―Followinginstructions‖and―notexperiencingcomplications‖arenotspecificcriteria.
s
―Adheringtonewregimen‖wouldbedifficulttomeasure.
DIF: CognitiveLevel:Applying(Application) TOP:NursingProcess:Planning
s
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
s s
5. Whichactivitybestreflectstheimplementationphaseofthenursingprocessforthepatientwhois
newlydiagnosedwithhypertension?
s
a. Providingeducationonkeepingajournalofbloodpressurereadings
b. Settinggoalsandoutcomecriteriawiththepatient‘sinput
c. Recordingadrughistoryregardingover-the-countermedicationsusedathome
d. Formulatinghumanneedsstatementsregardingdeficientknowledgerelatedtothenew
treatmentregimen
s
ANS:A s
Educationisaninterventionthatoccursduringtheimplementationphase.Settinggoalsandoutcomes
reflectstheplanningphase.Recordingadrughistoryreflectstheassessmentphase.Formulatinghuman
s
needsstatementsreflectsanalysisofdataaspartofplanning.
s
DIF: CognitiveLevel:Applying(Application)
TOP: NursingProcess:Implementation
s s
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
s
6. Themedicationorderreads,―Giveondansetron4mg,30minutesbeforebeginning
schemotherapytopreventnausea.‖Thenursenotesthattherouteismissingfromtheorder.What
isthenurse‘sbestaction?
s
a. Givethemedicationintravenouslybecausethepatientmightvomit.
b. Givethemedicationorallybecausethetabletsareavailablein4-mgdoses.
c. Contacttheprescribertoclarifytherouteofthemedicationordered.
d. Holdthemedicationuntiltheprescriberreturnstomakerounds.
ANS:C s
Acompletemedicationorderincludestherouteofadministration.Ifamedicationorderdoesnot
includetheroute,thenursemustasktheprescribertoclarifyit.Theintravenousandoralroutesare
s
notinterchangeable.Holdingthemedicationuntiltheprescriberreturnswouldmeanthatthe
s
spatientwouldnotreceiveaneededmedication.
DIF: CognitiveLevel:Applying(Application)
TOP: NursingProcess:Implementation
s s
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
s
PRIMEXAM.COM
, 7. Whenthenurseconsidersthetimingofadrugdose,whichfactorisappropriatetoconsiderwhen
decidingwhentogiveadrug?
s
a. Thepatient‘sabilitytoswallow
b. Thepatient‘sheight
c. Thepatient‘slastmeal
d. Thepatient‘sallergies
ANS:C s
Thenursemust consider specific pharmacokinetic/pharmacodynamic drugpropertiesthat may be
s s s s s s
affected by the timingofthelastmeal. Thepatient‘sability to swallow, height, andallergies arenot
s s s s s s s s s s
factorstoconsiderregardingthetimingofthedrug‘sadministration.
s
DIF: CognitiveLevel:Understanding(Comprehension)
TOP: NursingProcess:Assessment
s s
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
s
8. Thenurseisperforminganassessmentofanewlyadmittedpatient.Whichisanexampleof
subjectivedata?
s
a. Weight155pounds
b. Pulse72beats/minute
c. Thepatientreportsthatheusestheherbalproductginkgo
d. Thepatient‘scompletebloodcountresults
ANS:C s
Subjectivedataincludeinformationsharedthroughthespokenwordbyanyreliablesource,suchas
thepatient.Objectivedatamaybedefinedasanyinformationgatheredthroughthesensesorthat
s
swhichisseen,heard,felt,orsmelled.Apatient‘spulse,weight,andlaboratorytestsareallexamples
ofobjectivedata.
s
DIF: CognitiveLevel:Understanding(Comprehension)
TOP: NursingProcess:Assessment
s s
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
s
MULTIPLERESPONSE
1. Whengivingmedications,thenursewillfollowtherightsofmedicationadministration.Therights
include the right documentation, the right reason, the right response, and the patient‘s right to
s s s s s s s s s s s s s s s
refuse.Whichoftheseareadditionalrights?(Selectallthatapply.)
s
a. Rightdrug
b. Rightroute
c. Rightdose
d. Rightdiagnosis
e. Righttime
f. Rightpatient
ANS:A,B,C,E,F s
Additionalrightsofmedicationadministrationmustalwaysincludetherightdrug,rightdose,right
time,rightroute,andrightpatient.Therightdiagnosisisincorrect.
s
DIF: CognitiveLevel:Remembering (Knowledge) b
TOP: NursingProcess:Implementation
s s
PRIMEXAM.COM
, MSC: NCLEX:SafeandEffectiveCareEnvironment:SafetyandInfectionControl
s
OTHER
1. Placethephasesofthenursingprocessinthecorrectorder,with1asthefirstphaseand5asthelast
phase.
s
a. Planning
b. Evaluation
c. Assessment
d. Implementation
e. Humanneedsstatement
ANS:
C,E,A,D,B
Thenursingprocessisanongoingprocessthatbeginswithassessingandcontinueswithhuman
needsstatement,planning,implementing,andevaluating.
s
DIF: CognitiveLevel:Applying(Application) TOP:NursingProcess:General
s
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
s s
PRIMEXAM.COM
