,Chapter 1: Pharmacology and the Nursing Process in LPN
Practice
1.A nurse is preparing to administer a new scheduled
medication to a patient. Which action by the nurse best
demonstrates the "recognize cues" step of the Clinical
Judgment Measurement Model (CJMM)?
A. Verifying the patient's allergies on their chart and armband.
B. Documenting the medication administration in the
electronic health record.
C. Evaluating the patient's response 30 minutes after giving
the drug.
D. Checking the provider's order against the medication
administration record (MAR).
Correct Answer: A
Rationale: A is correct. "Recognize cues" involves identifying
relevant data, such as patient allergies, which is a critical
safety check before any drug administration. B describes the
"take action" step of documentation. C describes the
"evaluate outcomes" step. D describes the second safety
check of the rights of medication administration, which is part
of the "analyze cues" and "take action" processes.
Teaching Point: Recognizing cues involves gathering key data,
like allergies, before analyzing information or acting.
,2.
Chapter 1, Section: The LPN/VN’s Role and the Nursing
Process, Subsection: Using the Clinical Judgment Model
An LPN is reviewing a patient's chart and notes a new order
for furosemide. The patient's most recent potassium level is
3.2 mEq/L. Which step of the Clinical Judgment Measurement
Model (CJMM) is the LPN demonstrating by identifying the
potential for hypokalemia with this loop diuretic?
A. Take action
B. Generate solutions
C. Analyze cues
D. Evaluate outcomes
Correct Answer: C
Rationale: C is correct. "Analyze cues" involves processing the
information (low potassium level and a new order for a
potassium-wasting diuretic) to understand its significance and
anticipate potential problems. A, B, and D are subsequent
steps that involve implementing, planning, and assessing
interventions, which have not yet occurred.
Teaching Point: Analyzing cues requires synthesizing data to
identify trends, risks, and potential patient problems.
3.
Chapter 1, Section: The LPN/VN’s Role and the Nursing
Process, Subsection: Using the Clinical Judgment Model
After administering an antibiotic, a patient develops urticaria
and shortness of breath. The nurse administers
, diphenhydramine as per the standing protocol. This
intervention represents which step of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
Correct Answer: D
Rationale: D is correct. Implementation is the step where the
nurse carries out the planned interventions, such as
administering an antihistamine in response to an allergic
reaction. A (Assessment) would involve gathering data about
the reaction. B (Diagnosis) would involve identifying the
problem (e.g., allergic reaction). C (Planning) would involve
determining the appropriate action to take.
Teaching Point: Implementation is the action phase of the
nursing process, where planned interventions are executed.
4.
Chapter 1, Section: The LPN/VN’s Role and the Nursing
Process, Subsection: Using the Clinical Judgment Model
An LPN is contributing to a patient's plan of care. The RN has
written a nursing diagnosis of "Risk for Injury related to
drowsiness from antihistamine therapy." Which collaborative
action is most appropriate for the LPN to suggest for the plan?
A. Discontinue the antihistamine immediately.
B. Instruct the patient to request assistance when ambulating.
C. Administer a stimulant medication to counteract the
Practice
1.A nurse is preparing to administer a new scheduled
medication to a patient. Which action by the nurse best
demonstrates the "recognize cues" step of the Clinical
Judgment Measurement Model (CJMM)?
A. Verifying the patient's allergies on their chart and armband.
B. Documenting the medication administration in the
electronic health record.
C. Evaluating the patient's response 30 minutes after giving
the drug.
D. Checking the provider's order against the medication
administration record (MAR).
Correct Answer: A
Rationale: A is correct. "Recognize cues" involves identifying
relevant data, such as patient allergies, which is a critical
safety check before any drug administration. B describes the
"take action" step of documentation. C describes the
"evaluate outcomes" step. D describes the second safety
check of the rights of medication administration, which is part
of the "analyze cues" and "take action" processes.
Teaching Point: Recognizing cues involves gathering key data,
like allergies, before analyzing information or acting.
,2.
Chapter 1, Section: The LPN/VN’s Role and the Nursing
Process, Subsection: Using the Clinical Judgment Model
An LPN is reviewing a patient's chart and notes a new order
for furosemide. The patient's most recent potassium level is
3.2 mEq/L. Which step of the Clinical Judgment Measurement
Model (CJMM) is the LPN demonstrating by identifying the
potential for hypokalemia with this loop diuretic?
A. Take action
B. Generate solutions
C. Analyze cues
D. Evaluate outcomes
Correct Answer: C
Rationale: C is correct. "Analyze cues" involves processing the
information (low potassium level and a new order for a
potassium-wasting diuretic) to understand its significance and
anticipate potential problems. A, B, and D are subsequent
steps that involve implementing, planning, and assessing
interventions, which have not yet occurred.
Teaching Point: Analyzing cues requires synthesizing data to
identify trends, risks, and potential patient problems.
3.
Chapter 1, Section: The LPN/VN’s Role and the Nursing
Process, Subsection: Using the Clinical Judgment Model
After administering an antibiotic, a patient develops urticaria
and shortness of breath. The nurse administers
, diphenhydramine as per the standing protocol. This
intervention represents which step of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
Correct Answer: D
Rationale: D is correct. Implementation is the step where the
nurse carries out the planned interventions, such as
administering an antihistamine in response to an allergic
reaction. A (Assessment) would involve gathering data about
the reaction. B (Diagnosis) would involve identifying the
problem (e.g., allergic reaction). C (Planning) would involve
determining the appropriate action to take.
Teaching Point: Implementation is the action phase of the
nursing process, where planned interventions are executed.
4.
Chapter 1, Section: The LPN/VN’s Role and the Nursing
Process, Subsection: Using the Clinical Judgment Model
An LPN is contributing to a patient's plan of care. The RN has
written a nursing diagnosis of "Risk for Injury related to
drowsiness from antihistamine therapy." Which collaborative
action is most appropriate for the LPN to suggest for the plan?
A. Discontinue the antihistamine immediately.
B. Instruct the patient to request assistance when ambulating.
C. Administer a stimulant medication to counteract the
