Pharmacology
A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Easy
Question Type: Multiple Choice (Clinical Judgment)
Question:
A nurse is caring for a client who reports dizziness shortly after
receiving an antihypertensive medication. According to the
Clinical Judgment Measurement Model (CJMM), which action
best represents Recognize Cues?
A. Reassess the client's blood pressure and ask about additional
symptoms.
B. Lower the head of the bed immediately.
C. Notify the healthcare provider of suspected hypotension.
D. Hold the next scheduled dose of medication.
Correct Answer: A
Rationale: Recognize Cues involves collecting relevant
assessment data before making clinical decisions. Reassessing
vital signs and symptoms provides the information needed to
determine the client's condition.
Question 2
Difficulty: Moderate
,Question Type: Multiple Choice
Question:
A client receiving intravenous morphine becomes difficult to
arouse, has a respiratory rate of 8 breaths/minute, and oxygen
saturation of 88%. Which finding should the nurse identify as
the highest-priority cue?
A. The client rates pain as 2/10.
B. Respiratory rate of 8 breaths/minute.
C. The client has not eaten breakfast.
D. Intravenous site appears intact.
Correct Answer: B
Rationale: Respiratory depression is a life-threatening adverse
effect of opioid therapy. Recognizing this cue promptly guides
immediate intervention.
Question 3
Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
The nurse is assessing a client before administering digoxin.
Which assessment findings are examples of Recognize Cues?
(Select all that apply.)
, A. Apical pulse of 54 beats/minute.
B. Serum potassium level of 2.9 mEq/L.
C. Holding the medication.
D. Reviewing the client's reports of nausea.
E. Documenting the provider's new prescription.
Correct Answers: A, B, D
Rationale: Recognize Cues involves gathering assessment
information. Collecting pulse rate, laboratory values, and
symptom reports occurs before clinical decisions or
interventions are implemented.
Question 4
Difficulty: Moderate
Question Type: Multiple Choice
Question:
After reviewing assessment findings, the nurse concludes that a
client's confusion is most likely caused by hypoglycemia
following insulin administration. Which CJMM step is the nurse
demonstrating?
A. Recognize Cues
B. Analyze Cues
A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Easy
Question Type: Multiple Choice (Clinical Judgment)
Question:
A nurse is caring for a client who reports dizziness shortly after
receiving an antihypertensive medication. According to the
Clinical Judgment Measurement Model (CJMM), which action
best represents Recognize Cues?
A. Reassess the client's blood pressure and ask about additional
symptoms.
B. Lower the head of the bed immediately.
C. Notify the healthcare provider of suspected hypotension.
D. Hold the next scheduled dose of medication.
Correct Answer: A
Rationale: Recognize Cues involves collecting relevant
assessment data before making clinical decisions. Reassessing
vital signs and symptoms provides the information needed to
determine the client's condition.
Question 2
Difficulty: Moderate
,Question Type: Multiple Choice
Question:
A client receiving intravenous morphine becomes difficult to
arouse, has a respiratory rate of 8 breaths/minute, and oxygen
saturation of 88%. Which finding should the nurse identify as
the highest-priority cue?
A. The client rates pain as 2/10.
B. Respiratory rate of 8 breaths/minute.
C. The client has not eaten breakfast.
D. Intravenous site appears intact.
Correct Answer: B
Rationale: Respiratory depression is a life-threatening adverse
effect of opioid therapy. Recognizing this cue promptly guides
immediate intervention.
Question 3
Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
The nurse is assessing a client before administering digoxin.
Which assessment findings are examples of Recognize Cues?
(Select all that apply.)
, A. Apical pulse of 54 beats/minute.
B. Serum potassium level of 2.9 mEq/L.
C. Holding the medication.
D. Reviewing the client's reports of nausea.
E. Documenting the provider's new prescription.
Correct Answers: A, B, D
Rationale: Recognize Cues involves gathering assessment
information. Collecting pulse rate, laboratory values, and
symptom reports occurs before clinical decisions or
interventions are implemented.
Question 4
Difficulty: Moderate
Question Type: Multiple Choice
Question:
After reviewing assessment findings, the nurse concludes that a
client's confusion is most likely caused by hypoglycemia
following insulin administration. Which CJMM step is the nurse
demonstrating?
A. Recognize Cues
B. Analyze Cues
