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. Which nursing action best demonstrates the
Recognize Cues (Assessment) step of the Clinical Judgment
Measurement Model (CJMM)?
A. Comparing potential interventions for medication
administration
B. Reviewing the patient's allergies, vital signs, and current
medications
C. Administering the medication as prescribed
D. Evaluating whether the medication achieved the desired
effect
Correct Answer: B
Rationale: Recognizing cues involves collecting relevant patient
information before making clinical decisions. Reviewing
allergies, vital signs, and current medications helps identify
factors that influence medication safety.
,Question 2
Difficulty: Moderate
Question Type: Multiple Choice (MCQ)
Question:
A patient prescribed an antihypertensive medication has a
blood pressure of 88/54 mm Hg before the scheduled dose.
Which CJMM step is the nurse performing when determining
the significance of this finding?
A. Generate Solutions
B. Analyze Cues
C. Evaluate Outcomes
D. Take Action
Correct Answer: B
Rationale: Analyzing cues involves interpreting assessment
findings and determining their clinical significance. The nurse
considers whether the low blood pressure makes medication
administration unsafe.
Question 3
Difficulty: Moderate
Question Type: Select All That Apply (SATA)
, Question:
Which assessment findings should the nurse recognize as
important cues before administering insulin? Select all that
apply.
A. Current blood glucose level
B. Time of the patient's last meal
C. Skin color of the patient's roommate
D. Recent potassium level
E. Presence of symptoms of hypoglycemia
Correct Answer: A, B, D, E
Rationale: Blood glucose, meal timing, potassium level, and
symptoms of hypoglycemia directly affect insulin safety and
effectiveness. Information unrelated to the patient is not a
relevant cue.
Question 4
Difficulty: Moderate
Question Type: NGN Clinical Judgment
Question:
A nurse assesses a patient before administering digoxin.
Findings include:
• Apical pulse: 54 beats/min