A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Easy
Question Type: Multiple Choice
Question:
A nurse is preparing to administer a newly prescribed
medication. Before giving the medication, the nurse reviews the
patient's allergies, laboratory results, and current medications.
Which step of the Clinical Judgment Measurement Model
(CJMM) is the nurse performing?
A. Generate Solutions
B. Recognize Cues
C. Take Action
D. Evaluate Outcomes
Correct Answer: B. Recognize Cues
Rationale: Recognize Cues involves collecting relevant
assessment data before making clinical decisions. Reviewing
allergies, laboratory values, and current medications helps
identify information that may affect medication safety.
Question 2
Difficulty: Moderate
Question Type: Multiple Choice
,Question:
A patient prescribed an antihypertensive medication has a
blood pressure of 86/52 mm Hg and reports dizziness. What is
the nurse's priority action?
A. Administer the medication as prescribed.
B. Hold the medication and notify the provider.
C. Encourage the patient to ambulate.
D. Recheck the blood pressure after medication administration.
Correct Answer: B. Hold the medication and notify the provider.
Rationale: The patient's hypotension and dizziness suggest the
medication may worsen the condition. Recognizing these cues
and withholding the medication while notifying the provider
promotes patient safety.
Question 3
Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
Which assessment findings should the nurse recognize as cues
that may increase the risk of an adverse medication event?
(Select all that apply.)
A. Impaired kidney function
B. History of medication allergies
, C. Polypharmacy
D. Normal electrolyte values
E. Difficulty understanding instructions
Correct Answer: A, B, C, E
Rationale: Reduced renal function, allergies, multiple
medications, and limited understanding all increase medication-
related risk. Normal electrolyte values alone do not increase
medication risk.
Question 4
Difficulty: Moderate
Question Type: NGN Clinical Judgment
Question:
A patient receiving an opioid reports increasing sleepiness, has
a respiratory rate of 8 breaths/min, and an oxygen saturation of
89%.
Which action should the nurse perform first?
A. Document the findings.
B. Administer the next scheduled opioid dose.
C. Stop the opioid and assess the patient further while initiating
appropriate interventions.
D. Encourage oral fluids.