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 prepares to administer a newly prescribed
antihypertensive medication. Before giving the medication, the
nurse notices the patient's blood pressure is 88/54 mm Hg and
the patient reports dizziness when sitting upright. According to
the Clinical Judgment Measurement Model (CJMM), which
action best demonstrates Recognize Cues?
A. Hold the medication and notify the healthcare provider.
B. Review the patient's blood pressure, symptoms, and current
medications.
C. Develop alternative interventions for managing hypotension.
D. Reassess the patient's blood pressure after the provider
changes the prescription.
Correct Answer: B
Rationale:
Recognizing cues involves identifying and collecting relevant
clinical information before making a decision. Reviewing
,assessment findings, symptoms, and medication history
provides the data needed for clinical judgment.
Question 2
Difficulty: Moderate
Question Type: Multiple Choice (MCQ)
Question:
A postoperative patient receiving opioid analgesics has a
respiratory rate of 8 breaths/min, oxygen saturation of 89%,
and is difficult to awaken. Which CJMM step is the nurse
performing when determining that opioid-induced respiratory
depression is the most likely cause?
A. Recognize Cues
B. Analyze Cues
C. Take Action
D. Evaluate Outcomes
Correct Answer: B
Rationale:
Analyzing cues requires interpreting assessment findings to
determine their significance and identify the most likely clinical
, problem. The nurse connects abnormal findings to opioid-
induced respiratory depression before intervening.
Question 3
Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
A nurse is caring for a patient receiving intravenous antibiotics
for pneumonia. Which findings should the nurse recognize as
important clinical cues?
Select all that apply.
A. Temperature of 39.2°C (102.6°F)
B. White blood cell count of 18,000/mm³
C. Patient's favorite television program
D. Productive cough with green sputum
E. Oxygen saturation of 89% on room air
Correct Answer:
A, B, D, E
Rationale:
Relevant cues include abnormal vital signs, laboratory results,
respiratory symptoms, and oxygenation status. The patient's