A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Moderate
Question Type: NGN Clinical Judgment
Question:
A nurse is caring for a client who received a newly prescribed
antihypertensive medication 30 minutes ago. The client reports
dizziness when standing, and the blood pressure has decreased
from 168/94 mm Hg to 102/64 mm Hg.
Which assessment finding represents the nurse's Recognize
Cues step of clinical judgment?
A. Determining the medication may be causing orthostatic
hypotension
B. Identifying the blood pressure decrease and dizziness
C. Implementing fall precautions
D. Contacting the provider for additional orders
Correct Answer: B
Rationale: Recognize Cues involves collecting and identifying
relevant assessment data. The blood pressure decrease and
dizziness are assessment findings that must be recognized
before analysis or intervention.
Question 2
,Difficulty: Moderate
Question Type: Multiple Choice
Question:
A nurse reviews a client's medication profile and notes that a
newly prescribed drug can cause hypoglycemia. The client is
diaphoretic, shaky, and confused.
Which action demonstrates the Analyze Cues step?
A. Administering glucose tablets
B. Measuring blood glucose level
C. Determining the symptoms are consistent with hypoglycemia
D. Teaching the client about medication side effects
Correct Answer: C
Rationale: Analyze Cues involves interpreting assessment
findings and identifying their significance. Recognizing that the
symptoms indicate hypoglycemia is an analytical process.
Question 3
Difficulty: Difficult
Question Type: Prioritization
Question:
A nurse assesses four clients receiving medications.
, Which client should be prioritized during the Prioritize
Hypotheses step?
A. Client receiving an antibiotic who reports mild nausea
B. Client receiving insulin with a blood glucose of 42 mg/dL
C. Client receiving a stool softener who has not had a bowel
movement today
D. Client receiving a vitamin supplement who requests
discharge instructions
Correct Answer: B
Rationale: Severe hypoglycemia poses an immediate threat to
safety and requires the highest priority. Prioritization focuses on
identifying the most urgent problem requiring intervention.
Question 4
Difficulty: Moderate
Question Type: SATA
Question:
A nurse is caring for a client who developed a rash after
receiving a medication.
Which nursing actions represent the Generate Solutions step?
(Select all that apply.)