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 uses the Clinical Judgment Measurement Model
(CJMM) while preparing to administer a newly prescribed
medication. Which action best demonstrates the Recognize
Cues step?
A. Administering the medication according to the provider's
prescription
B. Reviewing the patient's allergies, current medications, and
vital signs before administration
C. Evaluating the patient's response after medication
administration
D. Teaching the patient about potential adverse effects
Correct Answer: B
Rationale: Recognize Cues involves collecting relevant
assessment data before making clinical decisions. Reviewing
allergies, medications, and vital signs helps identify factors that
may influence safe medication administration.
Question 2
,Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
A nurse is preparing to administer an antihypertensive
medication to a hospitalized patient. Which findings should the
nurse recognize as important cues before administering the
medication?
A. Blood pressure of 88/54 mm Hg
B. Patient reports dizziness upon standing
C. Heart rate of 54 beats/min
D. Patient ate breakfast
E. History of allergy to penicillin
Correct Answer: A, B, C
Rationale: Hypotension, dizziness, and bradycardia are
important assessment findings that may indicate the
medication should be withheld pending further evaluation.
Eating breakfast and a penicillin allergy are not directly relevant
to most antihypertensive medications.
Question 3
Difficulty: Moderate
Question Type: Multiple Choice
, Question:
After identifying that a patient's serum potassium level is
critically low, which CJMM step is the nurse performing when
determining that a prescribed loop diuretic may be contributing
to the abnormal result?
A. Recognize Cues
B. Analyze Cues
C. Take Action
D. Evaluate Outcomes
Correct Answer: B
Rationale: Analyze Cues requires interpreting assessment
findings and identifying relationships between data, such as
linking hypokalemia to loop diuretic therapy.
Question 4
Difficulty: Moderate
Question Type: Prioritization
Question:
A nurse is caring for four patients who are due to receive
medications. Which patient should be assessed first?
A. A patient receiving an opioid who reports increasing
drowsiness