Chapter 01: The Nursing Process and Drug Therapy
gg gg gg gg gg gg gg
Lilley: Pharmacology and the Nursing Process, 10th Edition
gg gg gg gg gg gg gg
MULTIPLE CHOICE gg
1. The nurse is developing a human needs statement for a patient who has a new
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
diagnosis of heart failure. Identification of human needs statements occur with
gg gg gg gg gg gg gg gg gg gg gg
which of these activities?
gg gg gg gg
a. Collection of patient data gg gg gg
b. Administering interventions gg
c. Deciding on patient outcomes gg gg gg
d. Documenting the patient‘s behavior gg gg gg
ANS: g g A
Identification of human needs occurs with the collection of patient data.
gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Understanding(Comprehension) aa gg
TOP:
gg Nursing Process: Human Needs Statement
g g gg gg gg gg
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
g g g g gg gg gg gg gg gg gg gg
2. The patient is to receive oral guaifenesin twice a day. Today, the nurse was busy and
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
gggave the medication 2 hours after the scheduled dose was due. What type of problem
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
ggdoes this represent?gg gg
a. ―Right time‖ g g
b. ―Right dose‖ g g
c. ―Right route‖ g g
d. ―Right medication‖ g g
ANS: g g A
―Right time‖ is correct because the medication was given more than 30 minutes after the
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
scheduled dose was due. ―Dose‖ is incorrect because the dose is not related to the time
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
the medication administration is scheduled.―Route‖ is incorrect because the route is not affected.
gg gg aa gg gg gg gg gg aa gg gg aa gg
―Medication‖ isincorrect becausethemedication ordered will not change.
gg gg gg aa gg aa
DIF: Cognitive Level: Applying (Application) gg gg aa
TOP:
gg Nursing Process: Implementation
g g gg gg
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
g g g g gg gg gg gg gg gg gg gg gg
3. The nurse has been monitoring the patient‘s progress on a new drug regimen
gg gg gg gg gg gg gg gg gg gg gg gg
since the first dose and documenting the patient‘s therapeutic response to the
gg gg gg gg gg gg gg gg gg gg gg gg
medication. Which phase of the nursing process do these actions illustrate?
gg gg gg gg gg gg gg gg gg gg gg
a. Human needs statement gg gg
b. Planning
c. Implementation
d. Evaluation
ANS: g g D
Monitoring the patient‘s progress, including the patient‘s response to the medication, is
gg gg gg gg gg gg gg gg gg gg gg
part of the evaluation phase. Planning, implementation, and human needs statement are
gg gg gg gg gg gg gg gg gg gg gg gg
not illustrated by this example.
gg g g gg gg gg
DIF: g g g g g g Cognitive Level: Understanding (Comprehension)
gg gg gg TOP: gg gg Nursing Process:
gg
PRIMEXAM.COM
, Evaluation
gg
PRIMEXAM.COM
, MSC: g g g g NCLEX: Safe and Effective Care Environment: Management of Care
gg gg gg gg gg gg gg gg
4. The nurse is assigned to a patient who is newly diagnosed with type 1 diabetes
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
gg mellitus. Which statement best illustrates an outcome criterion for this patient?
gg gg gg gg gg gg gg gg gg gg
a. The patient will follow instructions.
gg gg gg gg
b. The patient will not experience complications.
gg gg gg gg gg
c. The patient will adhere to the new insulin treatment regimen.
gg gg gg gg gg gg gg gg gg
d. The patient will demonstrate correct blood glucose testing technique.
gg gg gg gg gg gg gg gg
ANS: g g D
―Demonstrating correct blood glucose testing technique‖ is a specific and measurable
gg gg gg gg gg gg gg gg gg gg
outcomecriterion. ―Following instructions‖ and ―not experiencing complications‖ are not
gg gg aa gg gg gg gg gg g
specific criteria. ―Adhering to new regimen‖ would be difficult to measure.
gg gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Applying (Application) TOP: gg gg gg
Nursing Process: Planning MSC:
g g NCLEX: Safe and Effective Care
aa gg gg g g gg gg gg gg
Environment: Management of Care
gg gg gg gg
5. Which activity best reflects the implementation phase of the nursing process for the
gg gg gg gg gg gg gg gg gg gg gg gg
gg patient who is newly diagnosed with hypertension?
gg gg gg gg gg gg
a. Providing education on keeping a journal of blood pressure readings
gg gg gg gg gg gg gg gg gg
b. Setting goals and outcome criteria with the patient‘s input
gg gg gg gg gg gg gg gg
c. Recording a drug history regarding over-the-counter medications used at home
gg gg gg gg gg gg gg gg gg
d. Formulating human needs statements regarding deficient knowledge related to
gg gg gg gg gg gg gg gg
the new treatment regimen
gg gg gg gg
ANS: g g A
Education is an intervention that occurs during the implementation phase. Setting goals
gg gg gg gg gg gg gg gg gg gg gg
and outcomes reflects the planning phase. Recording a drug history reflects the
gg gg gg gg gg gg gg gg gg gg gg gg
assessment phase. Formulating human needs statements reflects analysis of data as part
gg gg gg gg gg gg gg gg gg gg gg gg
of planning.
gg gg
DIF: Cognitive Level: Applying (Application) gg gg aa
TOP:
gg Nursing Process: Implementation
g g gg gg
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
g g g g gg gg gg gg gg gg gg gg
6. The medication order reads, ―Give ondansetron 4 mg, 30 minutes before
gg gg gg gg gg gg gg gg gg gg
beginning chemotherapy to prevent nausea.‖ The nurse notes that the route is
gg gg gg gg gg gg gg gg gg gg gg gg
missing from the order. What is the nurse‘s best action?
gg gg gg gg gg gg gg gg gg gg
a. Give the medication intravenously because the patient might vomit.
gg gg gg gg gg gg gg gg
b. Give the medication orally because the tablets are available in 4-mg doses.
gg gg gg gg gg gg gg gg gg gg gg
c. Contact the prescriber to clarify the route of the medication ordered.
gg gg gg gg gg gg gg gg gg gg
d. Hold the medication until the prescriber returns to make rounds.
gg gg gg gg gg gg gg gg gg
ANS: g g C
A complete medication order includes the route of administration. If a medication order
gg gg gg gg gg gg gg gg gg gg gg gg
does not include the route, the nurse must ask the prescriber to clarify it. The
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
intravenous and oral routes are not interchangeable. Holding the medication until the
gg gg gg gg gg gg gg gg gg gg gg gg
prescriber returns would mean that the patient would not receive a needed medication.
gg gg gg gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Applying (Application) gg gg aa
TOP:
gg Nursing Process: Implementation
g g gg gg
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
g g g g gg gg gg gg gg gg gg gg
PRIMEXAM.COM
, 7. When the nurse considers the timing of a drug dose, which factor is appropriate to
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
ggconsider when deciding when to give a drug?
gg gg gg gg gg gg gg
a. The patient‘s ability to swallow
gg gg gg gg
b. The patient‘s heightgg gg
c. The patient‘s last meal
gg gg gg
d. The patient‘s allergies
gg gg
ANS: g g C
The nurse must consider specific pharmacokinetic/pharmacodynamic drug properties that
gg gg gg gg gg gg gg gg
may be affected by the timing of the last meal. The patient‘s ability to swallow,
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
height, and allergies are not factors to consider regarding the timing of the drug‘s
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
administration.
gg
DIF: Cognitive Level: Understanding(Comprehension) aa gg
TOP:
gg Nursing Process: Assessment
g g gg gg
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
g g g g gg gg gg gg gg gg gg gg
8. The nurse is performing an assessment of a newly admitted patient. Which is an
gg gg gg gg gg gg gg gg gg gg gg gg gg
ggexample of subjective data? gg gg gg
a. Weight 155 pounds gg gg
b. Pulse 72 beats/minute gg gg
c. The patient reports that he uses the herbal product ginkgo
gg gg gg gg gg gg gg gg gg
d. The patient‘s complete blood count results
gg gg gg gg gg
ANS: g g C
Subjective data include information shared through the spoken word by any reliable
gg gg gg gg gg gg gg gg gg gg gg
source, such as the patient. Objective data may be defined as any information
gg gg gg gg gg gg gg gg gg gg gg gg gg
gathered through the senses or that which is seen, heard, felt, or smelled. A patient‘s
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
pulse, weight, and laboratory tests are all examples of objective data.
gg gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Understanding(Comprehension) aa gg
TOP:
gg Nursing Process: Assessment
g g gg gg
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
g g g g gg gg gg gg gg gg gg gg
MULTIPLE RESPONSE gg
1. When giving medications, the nurse will follow the rights of medication administration.
gg gg gg gg gg gg gg gg gg gg gg
ggThe rights include the right documentation, the right reason, the right response, and
gg gg gg gg gg gg gg gg gg gg gg gg
ggthe patient‘s right to refuse. Which of these are additional rights? (Select all that
g g gg gg gg gg gg gg gg gg gg gg gg gg
ggapply.)
a. Right drug gg
b. Right route gg
c. Right dose gg
d. Right diagnosis gg
e. Right time gg
f. Right patient gg
ANS: g g A, B, C, E, F gg gg gg gg
Additional rights of medication administration must always include the right drug, right
gg gg gg gg gg gg gg gg gg gg gg
dose, right time, right route, and right patient. The right diagnosis is incorrect.
gg gg gg gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Remembering (Knowledge) aa gg aa
PRIMEXAM.COM
gg gg gg gg gg gg gg
Lilley: Pharmacology and the Nursing Process, 10th Edition
gg gg gg gg gg gg gg
MULTIPLE CHOICE gg
1. The nurse is developing a human needs statement for a patient who has a new
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
diagnosis of heart failure. Identification of human needs statements occur with
gg gg gg gg gg gg gg gg gg gg gg
which of these activities?
gg gg gg gg
a. Collection of patient data gg gg gg
b. Administering interventions gg
c. Deciding on patient outcomes gg gg gg
d. Documenting the patient‘s behavior gg gg gg
ANS: g g A
Identification of human needs occurs with the collection of patient data.
gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Understanding(Comprehension) aa gg
TOP:
gg Nursing Process: Human Needs Statement
g g gg gg gg gg
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
g g g g gg gg gg gg gg gg gg gg
2. The patient is to receive oral guaifenesin twice a day. Today, the nurse was busy and
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
gggave the medication 2 hours after the scheduled dose was due. What type of problem
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
ggdoes this represent?gg gg
a. ―Right time‖ g g
b. ―Right dose‖ g g
c. ―Right route‖ g g
d. ―Right medication‖ g g
ANS: g g A
―Right time‖ is correct because the medication was given more than 30 minutes after the
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
scheduled dose was due. ―Dose‖ is incorrect because the dose is not related to the time
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
the medication administration is scheduled.―Route‖ is incorrect because the route is not affected.
gg gg aa gg gg gg gg gg aa gg gg aa gg
―Medication‖ isincorrect becausethemedication ordered will not change.
gg gg gg aa gg aa
DIF: Cognitive Level: Applying (Application) gg gg aa
TOP:
gg Nursing Process: Implementation
g g gg gg
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
g g g g gg gg gg gg gg gg gg gg gg
3. The nurse has been monitoring the patient‘s progress on a new drug regimen
gg gg gg gg gg gg gg gg gg gg gg gg
since the first dose and documenting the patient‘s therapeutic response to the
gg gg gg gg gg gg gg gg gg gg gg gg
medication. Which phase of the nursing process do these actions illustrate?
gg gg gg gg gg gg gg gg gg gg gg
a. Human needs statement gg gg
b. Planning
c. Implementation
d. Evaluation
ANS: g g D
Monitoring the patient‘s progress, including the patient‘s response to the medication, is
gg gg gg gg gg gg gg gg gg gg gg
part of the evaluation phase. Planning, implementation, and human needs statement are
gg gg gg gg gg gg gg gg gg gg gg gg
not illustrated by this example.
gg g g gg gg gg
DIF: g g g g g g Cognitive Level: Understanding (Comprehension)
gg gg gg TOP: gg gg Nursing Process:
gg
PRIMEXAM.COM
, Evaluation
gg
PRIMEXAM.COM
, MSC: g g g g NCLEX: Safe and Effective Care Environment: Management of Care
gg gg gg gg gg gg gg gg
4. The nurse is assigned to a patient who is newly diagnosed with type 1 diabetes
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
gg mellitus. Which statement best illustrates an outcome criterion for this patient?
gg gg gg gg gg gg gg gg gg gg
a. The patient will follow instructions.
gg gg gg gg
b. The patient will not experience complications.
gg gg gg gg gg
c. The patient will adhere to the new insulin treatment regimen.
gg gg gg gg gg gg gg gg gg
d. The patient will demonstrate correct blood glucose testing technique.
gg gg gg gg gg gg gg gg
ANS: g g D
―Demonstrating correct blood glucose testing technique‖ is a specific and measurable
gg gg gg gg gg gg gg gg gg gg
outcomecriterion. ―Following instructions‖ and ―not experiencing complications‖ are not
gg gg aa gg gg gg gg gg g
specific criteria. ―Adhering to new regimen‖ would be difficult to measure.
gg gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Applying (Application) TOP: gg gg gg
Nursing Process: Planning MSC:
g g NCLEX: Safe and Effective Care
aa gg gg g g gg gg gg gg
Environment: Management of Care
gg gg gg gg
5. Which activity best reflects the implementation phase of the nursing process for the
gg gg gg gg gg gg gg gg gg gg gg gg
gg patient who is newly diagnosed with hypertension?
gg gg gg gg gg gg
a. Providing education on keeping a journal of blood pressure readings
gg gg gg gg gg gg gg gg gg
b. Setting goals and outcome criteria with the patient‘s input
gg gg gg gg gg gg gg gg
c. Recording a drug history regarding over-the-counter medications used at home
gg gg gg gg gg gg gg gg gg
d. Formulating human needs statements regarding deficient knowledge related to
gg gg gg gg gg gg gg gg
the new treatment regimen
gg gg gg gg
ANS: g g A
Education is an intervention that occurs during the implementation phase. Setting goals
gg gg gg gg gg gg gg gg gg gg gg
and outcomes reflects the planning phase. Recording a drug history reflects the
gg gg gg gg gg gg gg gg gg gg gg gg
assessment phase. Formulating human needs statements reflects analysis of data as part
gg gg gg gg gg gg gg gg gg gg gg gg
of planning.
gg gg
DIF: Cognitive Level: Applying (Application) gg gg aa
TOP:
gg Nursing Process: Implementation
g g gg gg
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
g g g g gg gg gg gg gg gg gg gg
6. The medication order reads, ―Give ondansetron 4 mg, 30 minutes before
gg gg gg gg gg gg gg gg gg gg
beginning chemotherapy to prevent nausea.‖ The nurse notes that the route is
gg gg gg gg gg gg gg gg gg gg gg gg
missing from the order. What is the nurse‘s best action?
gg gg gg gg gg gg gg gg gg gg
a. Give the medication intravenously because the patient might vomit.
gg gg gg gg gg gg gg gg
b. Give the medication orally because the tablets are available in 4-mg doses.
gg gg gg gg gg gg gg gg gg gg gg
c. Contact the prescriber to clarify the route of the medication ordered.
gg gg gg gg gg gg gg gg gg gg
d. Hold the medication until the prescriber returns to make rounds.
gg gg gg gg gg gg gg gg gg
ANS: g g C
A complete medication order includes the route of administration. If a medication order
gg gg gg gg gg gg gg gg gg gg gg gg
does not include the route, the nurse must ask the prescriber to clarify it. The
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
intravenous and oral routes are not interchangeable. Holding the medication until the
gg gg gg gg gg gg gg gg gg gg gg gg
prescriber returns would mean that the patient would not receive a needed medication.
gg gg gg gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Applying (Application) gg gg aa
TOP:
gg Nursing Process: Implementation
g g gg gg
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
g g g g gg gg gg gg gg gg gg gg
PRIMEXAM.COM
, 7. When the nurse considers the timing of a drug dose, which factor is appropriate to
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
ggconsider when deciding when to give a drug?
gg gg gg gg gg gg gg
a. The patient‘s ability to swallow
gg gg gg gg
b. The patient‘s heightgg gg
c. The patient‘s last meal
gg gg gg
d. The patient‘s allergies
gg gg
ANS: g g C
The nurse must consider specific pharmacokinetic/pharmacodynamic drug properties that
gg gg gg gg gg gg gg gg
may be affected by the timing of the last meal. The patient‘s ability to swallow,
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
height, and allergies are not factors to consider regarding the timing of the drug‘s
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
administration.
gg
DIF: Cognitive Level: Understanding(Comprehension) aa gg
TOP:
gg Nursing Process: Assessment
g g gg gg
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
g g g g gg gg gg gg gg gg gg gg
8. The nurse is performing an assessment of a newly admitted patient. Which is an
gg gg gg gg gg gg gg gg gg gg gg gg gg
ggexample of subjective data? gg gg gg
a. Weight 155 pounds gg gg
b. Pulse 72 beats/minute gg gg
c. The patient reports that he uses the herbal product ginkgo
gg gg gg gg gg gg gg gg gg
d. The patient‘s complete blood count results
gg gg gg gg gg
ANS: g g C
Subjective data include information shared through the spoken word by any reliable
gg gg gg gg gg gg gg gg gg gg gg
source, such as the patient. Objective data may be defined as any information
gg gg gg gg gg gg gg gg gg gg gg gg gg
gathered through the senses or that which is seen, heard, felt, or smelled. A patient‘s
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
pulse, weight, and laboratory tests are all examples of objective data.
gg gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Understanding(Comprehension) aa gg
TOP:
gg Nursing Process: Assessment
g g gg gg
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
g g g g gg gg gg gg gg gg gg gg
MULTIPLE RESPONSE gg
1. When giving medications, the nurse will follow the rights of medication administration.
gg gg gg gg gg gg gg gg gg gg gg
ggThe rights include the right documentation, the right reason, the right response, and
gg gg gg gg gg gg gg gg gg gg gg gg
ggthe patient‘s right to refuse. Which of these are additional rights? (Select all that
g g gg gg gg gg gg gg gg gg gg gg gg gg
ggapply.)
a. Right drug gg
b. Right route gg
c. Right dose gg
d. Right diagnosis gg
e. Right time gg
f. Right patient gg
ANS: g g A, B, C, E, F gg gg gg gg
Additional rights of medication administration must always include the right drug, right
gg gg gg gg gg gg gg gg gg gg gg
dose, right time, right route, and right patient. The right diagnosis is incorrect.
gg gg gg gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Remembering (Knowledge) aa gg aa
PRIMEXAM.COM
