A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Easy
Question Type: Multiple Choice (MCQ)
Question:
A nurse is preparing to administer a newly prescribed
medication. Which nursing action best demonstrates the
Recognize Cues (Assessment) step of the Clinical Judgment
Measurement Model (CJMM)?
A. Reviewing the patient's allergy history, current vital signs,
and laboratory results
B. Deciding to hold the medication because of abnormal
laboratory findings
C. Developing a plan to monitor the patient after medication
administration
D. Evaluating whether the medication achieved the desired
therapeutic effect
Correct Answer: A
Rationale: Recognizing cues involves collecting relevant patient
information before making clinical decisions. Allergy history,
assessment findings, and laboratory values provide essential
data for safe medication administration.
,Question 2
Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
A nurse is assessing a patient before administering an
antihypertensive medication. Which assessment findings should
be recognized as clinically significant cues?
A. Blood pressure of 88/54 mm Hg
B. Serum potassium level of 5.8 mEq/L
C. Patient reports dizziness when standing
D. Favorite television program begins in 15 minutes
E. Heart rate of 48 beats/min
Correct Answer: A, B, C, E
Rationale: Hypotension, hyperkalemia, dizziness, and
bradycardia are important assessment findings that may affect
medication safety. The patient's television schedule is unrelated
to medication administration.
Question 3
Difficulty: Moderate
Question Type: NGN Clinical Judgment
, Question:
A patient with heart failure is prescribed a scheduled dose of a
diuretic. Assessment reveals:
• Blood pressure: 90/56 mm Hg
• Heart rate: 108 beats/min
• Serum potassium: 2.9 mEq/L
• Reports muscle weakness
Which finding should the nurse prioritize when analyzing cues?
A. Elevated heart rate
B. Low potassium level with muscle weakness
C. Low blood pressure alone
D. History of heart failure
Correct Answer: B
Rationale: Severe hypokalemia places the patient at immediate
risk for life-threatening dysrhythmias, particularly before
administering a potassium-wasting diuretic. This finding
requires prompt intervention.
Question 4
Difficulty: Moderate
Question Type: Multiple Choice (MCQ)