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