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, laboratory values, and
vital signs. Which step of the Clinical Judgment Measurement
Model (CJMM) is the nurse performing?
A. Take Action
B. Recognize Cues
C. Evaluate Outcomes
D. Generate Solutions
Correct Answer: B. Recognize Cues
Rationale: Recognize Cues involves collecting and validating
relevant patient information before making clinical decisions.
Reviewing assessment findings helps identify factors that may
influence medication safety.
Question 2
Difficulty: Moderate
Question Type: Multiple Choice (MCQ)
,Question:
A patient receiving an antihypertensive medication reports
dizziness upon standing. Which nursing action best reflects the
Analyze Cues phase of the CJMM?
A. Document the patient's complaint.
B. Determine whether the dizziness is related to orthostatic
hypotension.
C. Instruct the patient to change positions slowly.
D. Hold the next medication dose.
Correct Answer: B. Determine whether the dizziness is related
to orthostatic hypotension.
Rationale: Analyze Cues involves interpreting assessment
findings to determine their clinical significance before selecting
interventions.
Question 3
Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
A nurse is assessing a patient before administering digoxin.
Which findings should be recognized as important cues? (Select
all that apply.)
, A. Apical pulse of 52 beats/min
B. Serum potassium level of 2.9 mEq/L
C. Reports of nausea today
D. Blood glucose of 108 mg/dL
E. Complaint of blurred vision
Correct Answers: A, B, C, E
Rationale: Bradycardia, hypokalemia, nausea, and visual
disturbances may indicate increased risk for digoxin toxicity. A
normal blood glucose level is not directly relevant.
Question 4
Difficulty: Moderate
Question Type: NGN Clinical Judgment
Question:
A patient with bacterial pneumonia is prescribed an intravenous
antibiotic. Before administration, the nurse notes a
documented allergy to the same antibiotic class.
Which action best demonstrates prioritizing hypotheses?
A. Administer the medication while monitoring closely.
B. Determine that the patient may be at risk for a serious
allergic reaction.