A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Moderate
Question Type: NGN Clinical Judgment (MCQ)
Question:
A nurse is preparing to administer a newly prescribed
antihypertensive medication. Before administration, the nurse
notes the patient's blood pressure is 86/54 mm Hg and the
patient reports dizziness upon standing.
Which nursing action best demonstrates the Recognize Cues
step of the Clinical Judgment Measurement Model (CJMM)?
A. Holding the medication after determining it may worsen
hypotension
B. Measuring the patient's blood pressure and documenting the
dizziness
C. Contacting the provider to request a dosage adjustment
D. Educating the patient about orthostatic hypotension
Correct Answer: B
Rationale:
Recognize Cues involves identifying relevant assessment
findings. Measuring and documenting hypotension and
dizziness gathers essential information before further analysis
or intervention.
,Question 2
Difficulty: Moderate
Question Type: Multiple Choice
Question:
A nurse reviews the following assessment findings before
administering insulin:
• Blood glucose: 58 mg/dL
• Patient is diaphoretic
• Patient reports shakiness
Which action represents Analyze Cues?
A. Comparing the findings and determining the patient is
experiencing hypoglycemia
B. Administering the scheduled insulin immediately
C. Recording the assessment findings in the chart
D. Teaching the patient about insulin storage
Correct Answer: A
Rationale:
Analyze Cues requires interpreting assessment data to identify a
, clinical problem. The findings collectively indicate
hypoglycemia.
Question 3
Difficulty: Moderate
Question Type: SATA
Question:
A nurse prepares to administer an opioid analgesic.
Which assessments are examples of Recognize Cues? (Select all
that apply.)
A. Respiratory rate
B. Pain intensity
C. Oxygen saturation
D. Deciding to withhold the medication
E. Level of consciousness
Correct Answers:
A, B, C, E
Rationale:
Recognize Cues includes collecting assessment information
before medication administration. Deciding to withhold the
medication occurs after analysis.