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. Before giving the first dose, the nurse reviews the
patient's allergies, current medications, vital signs, and recent
laboratory values. Which component of the Clinical Judgment
Measurement Model (CJMM) is the nurse demonstrating?
A. Generate Solutions
B. Recognize Cues
C. Take Action
D. Evaluate Outcomes
Correct Answer: B. Recognize Cues
Rationale: Recognizing cues involves gathering and identifying
relevant patient information before making clinical decisions.
Reviewing assessment data helps identify factors that may
influence medication safety.
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 important clinical cues?
A. Blood pressure is 88/54 mm Hg.
B. Heart rate is 52 beats/min.
C. Patient reports dizziness when standing.
D. Patient's favorite television program begins in 15 minutes.
E. Serum potassium is 5.8 mEq/L.
Correct Answers: A, B, C, E
Rationale: Hypotension, bradycardia, dizziness, and
hyperkalemia are significant cues that may affect medication
administration. The patient's television schedule is unrelated to
safe medication management.
Question 3
Difficulty: Moderate
Question Type: NGN Clinical Judgment
Question:
A patient scheduled to receive insulin has a blood glucose level
of 62 mg/dL and reports shakiness and sweating. Which nursing
action is most appropriate?
, A. Administer the prescribed insulin immediately.
B. Hold the insulin, treat the hypoglycemia, and notify the
provider as appropriate.
C. Encourage the patient to ambulate before receiving insulin.
D. Administer insulin after documenting the symptoms.
Correct Answer: B. Hold the insulin, treat the hypoglycemia,
and notify the provider as appropriate.
Rationale: The assessment findings indicate hypoglycemia.
Treating the low blood glucose before administering insulin
helps prevent further harm.
Question 4
Difficulty: Moderate
Question Type: Multiple Choice (MCQ)
Question:
After collecting assessment data, the nurse determines that a
patient's elevated creatinine level increases the risk for
medication toxicity. Which CJMM step is being demonstrated?
A. Recognize Cues
B. Analyze Cues
C. Take Action
D. Evaluate Outcomes