A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Moderate
Question Type: MCQ
Question:
A nurse reviews a patient’s chart and notes a potassium level of
2.9 mEq/L after receiving a loop diuretic. Which step of the
Clinical Judgment Management Model (CJMM) is the nurse
performing?
A. Take Action
B. Recognize Cues
C. Evaluate Outcomes
D. Generate Solutions
Correct Answer:
B
Rationale:
Recognizing cues involves identifying relevant clinical data such
as lab values and medication effects. The nurse is identifying
abnormal potassium levels, which is part of the assessment
phase.
Question 2
Difficulty: Moderate
Question Type: MCQ
,Question:
After identifying that a patient is experiencing dizziness related
to antihypertensive medication, what is the nurse’s next CJMM
step?
A. Take Action
B. Analyze Cues
C. Evaluate Outcomes
D. Implement Teaching
Correct Answer:
B
Rationale:
Analyzing cues involves interpreting collected data and linking
symptoms (dizziness) to possible causes (antihypertensive
effects). This step helps determine clinical significance before
planning care.
Question 3
Difficulty: Difficult
Question Type: SATA
Question:
A nurse is prioritizing hypotheses for a patient receiving opioid
analgesics. Which findings require immediate attention? Select
all that apply.
, A. Respiratory rate of 8 breaths/min
B. Oxygen saturation of 89%
C. Patient reports mild nausea
D. Sedation score indicating unresponsiveness
E. Pain score of 6/10
Correct Answer:
A, B, D
Rationale:
Respiratory depression, hypoxia, and unresponsiveness indicate
opioid toxicity and are life-threatening. Mild nausea and
moderate pain are expected effects and lower priority.
Question 4
Difficulty: Moderate
Question Type: MCQ
Question:
The nurse develops a plan to administer an antiemetic before
chemotherapy to prevent nausea. Which CJMM step is this?
A. Generate Solutions
B. Analyze Cues
C. Evaluate Outcomes
D. Recognize Cues