A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Easy
Question Type: Multiple Choice
Question:
A nurse is administering a newly prescribed medication. Which
action best reflects the Recognize Cues step of the Clinical
Judgment Management Model (CJMM)?
A. Administering the medication as prescribed
B. Reviewing the patient's allergies, vital signs, and current
medications before administration
C. Evaluating whether the medication achieved the desired
effect
D. Contacting the provider to request a dosage adjustment
Correct Answer: B
Rationale:
Recognizing cues involves collecting relevant assessment data
before making clinical decisions. Reviewing allergies, vital signs,
and current medications helps identify factors that may affect
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 are
examples of Recognize Cues?
A. Blood pressure of 88/54 mm Hg
B. History of allergy to sulfonamides
C. Patient reports dizziness upon standing
D. Nurse decides to hold the medication
E. Current serum potassium level
Correct Answer: A, B, C, E
Rationale:
Recognizing cues involves gathering objective and subjective
assessment data. Holding the medication is an intervention, not
an assessment activity.
Question 3
Difficulty: Moderate
Question Type: Multiple Choice
Question:
After identifying that a patient has hypotension, dizziness, and a
, recent dose of an antihypertensive medication, which CJMM
step should the nurse perform next?
A. Evaluate outcomes
B. Analyze cues
C. Take action
D. Generate solutions
Correct Answer: B
Rationale:
After collecting assessment data, the nurse analyzes the
information to determine relationships and identify potential
clinical problems before planning interventions.
Question 4
Difficulty: Difficult
Question Type: NGN Clinical Judgment
Question:
A patient receiving intravenous opioids is difficult to arouse.
Respiratory rate is 8 breaths/min, oxygen saturation is 88%, and
pupils are pinpoint.
Which finding should the nurse prioritize?
A. Pinpoint pupils
B. Respiratory depression