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 medication, the nurse reviews the
patient's allergies, current medications, and vital signs. Which
step of the Clinical Judgment Measurement Model (CJMM) is
the nurse demonstrating?
A. Analyze cues
B. Recognize cues
C. Generate solutions
D. Evaluate outcomes
Correct Answer: B. Recognize cues
Rationale: Recognizing cues involves collecting and identifying
relevant patient information before making clinical decisions.
Reviewing allergies, medications, and assessment findings
provides 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 important clinical cues?
Select all that apply.
A. Blood pressure of 88/54 mm Hg
B. History of dizziness after standing
C. Heart rate of 56 beats/min
D. Favorite television program
E. Current potassium level
Correct Answer: A, B, C, E
Rationale: Blood pressure, heart rate, orthostatic symptoms,
and electrolyte values directly influence medication safety. A
patient's television preference is unrelated to medication
assessment.
Question 3
Difficulty: Moderate
Question Type: Multiple Choice (Clinical Judgment)
, Question:
A patient is prescribed an opioid analgesic. Before
administration, the nurse notes a respiratory rate of 8
breaths/min and difficulty arousing the patient. Which action
best demonstrates the "Analyze Cues" step?
A. Administer the medication as prescribed.
B. Determine that the patient may be experiencing excessive
sedation and increased risk for respiratory depression.
C. Reassess pain in 4 hours.
D. Document the respiratory rate without further action.
Correct Answer: B
Rationale: Analyzing cues requires interpreting assessment
findings and identifying potential clinical problems. Excessive
sedation and slow respirations suggest the medication may be
unsafe to administer.
Question 4
Difficulty: Moderate
Question Type: Prioritization
Question: