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
antihypertensive medication. Before giving the medication, the
nurse reviews the client's blood pressure, pulse, allergy history,
and recent laboratory results. Which step 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 collecting and identifying relevant
assessment information before making clinical decisions.
Reviewing vital signs, allergies, and laboratory results provides
essential data needed for safe medication administration.
Question 2
,Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
Which assessment findings should the nurse recognize as
important cues before administering digoxin?
A. Apical pulse of 54 beats/minute
B. Serum potassium of 2.9 mEq/L
C. Blood pressure of 122/74 mm Hg
D. Complaint of nausea and blurred vision
E. Oxygen saturation of 98% on room air
Correct Answer: A, B, D
Rationale:
A low apical pulse, hypokalemia, and symptoms such as nausea
and blurred vision may indicate an increased risk for digoxin
toxicity. These findings require further evaluation before
administering the medication.
Question 3
Difficulty: Moderate
Question Type: NGN Clinical Judgment
Question:
A client receiving intravenous morphine becomes increasingly
, drowsy, has a respiratory rate of 8 breaths/minute, and oxygen
saturation decreases to 88%.
Which hypothesis should the nurse prioritize?
A. Anxiety related to hospitalization
B. Opioid-induced respiratory depression
C. Acute dehydration
D. Mild medication intolerance
Correct Answer: B. Opioid-induced respiratory depression
Rationale:
The client's decreased respiratory rate, reduced oxygen
saturation, and excessive sedation are consistent with opioid-
induced respiratory depression, which requires immediate
intervention.
Question 4
Difficulty: Moderate
Question Type: Multiple Choice (MCQ)
Question:
While reviewing a medication order, the nurse notices that the
prescribed dose is significantly higher than the usual
recommended dose. Which nursing action best reflects the
Generate Solutions step of the CJMM?