Chapterg01:gThegNursinggProcessgandgDruggTherapygLilley:gPharmacologygandgthegNur
singgProcess,g10thgEditiong g
g
MULTIPLEgCHOICEg
g
1. Thegnursegisgdevelopinggaghumangneedsgstatementgforgagpatientgwhoghasgagnewgdiagnosisgofgh
eartgfailure.gIdentificationgofghumangneedsgstatementsgoccurgwithgwhichgofgthesegactivities?ga.
gCollectiongofgpatientgdatag
b. Administeringginterventionsg
c. Decidinggongpatientgoutcomesg
d. Documentinggthegpatient‘sgbehaviorg
ANS:gAg
Identificationgofghumangneedsgoccursgwithgthegcollectiongofgpatientgdata.g
g
DIF:gCognitivegLevel:gUnderstandingg(Comprehension)g
TOP:gNursinggProcess:gHumangNeedsgStatementg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gManagementgofgCareg
g
2. Thegpatientgisgtogreceivegoralgguaifenesingtwicegagday.gToday,gthegnursegwasgbusygandggavegt
hegmedicationg2ghoursgaftergthegscheduledgdosegwasgdue.gWhatgtypegofgproblemgdoesgthisgrep
resent?g
a. ―Rightgtime‖g
b. ―Rightgdose‖g
c. ―Rightgroute‖g
d. ―Rightgmedication‖g
ANS:gAg
―Rightgtime‖gisgcorrectgbecausegthegmedicationgwasggivengmoregthang30gminutesgaftergthegsch
eduledgdosegwasgdue.g―Dose‖gisgincorrectgbecausegthegdosegisgnotgrelatedgtogthegtimegthegmed
icationgadministrationgisgscheduled.g―Route‖gisgincorrectgbecausegthegroutegisgnotgaffected.g―
Medication‖gisgincorrectgbecausegthegmedicationgorderedgwillgnotgchange.g
g
DIF:gCognitivegLevel:gApplyingg(Application)g
TOP:gNursinggProcess:gImplementationg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gSafetygandgInfectiongControlg
g
3. Thegnurseghasgbeengmonitoringgthegpatient‘sgprogressgongagnewgdruggregimengsincegthegfirstgd
osegandgdocumentinggthegpatient‘sgtherapeuticgresponsegtogthegmedication.gWhichgphasegofgth
egnursinggprocessgdogthesegactionsgillustrate?ga.gHumangneedsgstatementg
b. Planningg
c. Implementationg
d. Evaluationg
ANS:gDg
Monitoringgthegpatient‘sgprogress,gincludinggthegpatient‘sgresponsegtogthegmedication,gisgpartgo
fgthegevaluationgphase.gPlanning,gimplementation,gandghumangneedsgstatementgaregnotgillustrat
edgbygthisgexample.g
g
DIF:gggCognitivegLevel:gUnderstandingg(Comprehension)g TOP:gNursinggProcess:gEvaluationg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gManagementgofgCareg
g
4. Thegnursegisgassignedgtogagpatientgwhogisgnewlygdiagnosedgwithgtypeg1gdiabetesgmellitus.g
, Whichgstatementgbestgillustratesgangoutcomegcriteriongforgthisgpatient?g
a.gThegpatientgwillgfollowginstructions.g
b. Thegpatientgwillgnotgexperiencegcomplications.g
c. Thegpatientgwillgadheregtogthegnewginsulingtreatmentgregimen.g
d. Thegpatientgwillgdemonstrategcorrectgbloodgglucosegtestinggtechnique.g
ANS:gDg
―Demonstratinggcorrectgbloodgglucosegtestinggtechnique‖gisgagspecificgandgmeasurablegoutco
megcriterion.g―Followingginstructions‖gandg―notgexperiencinggcomplications‖garegnotgspecif
icgcriteria.g―Adheringgtognewgregimen‖gwouldgbegdifficultgtogmeasure.g
g
DIF:gCognitivegLevel:gApplyingg(Application)g
TOP:gNursinggProcess:gPlanninggMSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gMana
gementgofgCareg
g
5. Whichgactivitygbestgreflectsgthegimplementationgphasegofgthegnursinggprocessgforgthegpatientg
whogisgnewlygdiagnosedgwithghypertension?g
a. Providinggeducationgongkeepinggagjournalgofgbloodgpressuregreadingsg
b. Settingggoalsgandgoutcomegcriteriagwithgthegpatient‘sginputg
c. Recordinggagdrugghistorygregardinggover-the-countergmedicationsgusedgatghomeg
d. Formulatingghumangneedsgstatementsgregardinggdeficientgknowledgegrelatedgtogthegnewgtre
atmentgregimeng
ANS:gAg
Educationgisganginterventiongthatgoccursgduringgthegimplementationgphase.gSettingggoalsgandgo
utcomesgreflectsgthegplanninggphase.gRecordinggagdrugghistorygreflectsgthegassessmentgphase.g
Formulatingghumangneedsgstatementsgreflectsganalysisgofgdatagasgpartgofgplanning.g
g
DIF:gCognitivegLevel:gApplyingg(Application)g
TOP:gNursinggProcess:gImplementationg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gManagementgofgCareg
g
6. Thegmedicationgordergreads,g―Givegondansetrong4gmg,g30gminutesgbeforegbeginninggchemot
herapygtogpreventgnausea.‖gThegnursegnotesgthatgthegroutegisgmissinggfromgthegorder.gWhatgisgt
hegnurse‘sgbestgaction?g
a. Givegthegmedicationgintravenouslygbecausegthegpatientgmightgvomit.g
b. Givegthegmedicationgorallygbecausegthegtabletsgaregavailableging4-mggdoses.g
c. Contactgthegprescribergtogclarifygthegroutegofgthegmedicationgordered.g
d. Holdgthegmedicationguntilgthegprescribergreturnsgtogmakegrounds.g
ANS:gCg
Agcompletegmedicationgordergincludesgthegroutegofgadministration.gIfgagmedicationgordergdoesg
notgincludegthegroute,gthegnursegmustgaskgthegprescribergtogclarifygit.gThegintravenousgandgoralg
routesgaregnotginterchangeable.gHoldinggthegmedicationguntilgthegprescribergreturnsgwouldgmea
ngthatgthegpatientgwouldgnotgreceivegagneededgmedication.g
g
DIF:gCognitivegLevel:gApplyingg(Application)g
TOP:gNursinggProcess:gImplementationg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gManagementgofgCareg
7. Whengthegnursegconsidersgthegtiminggofgagdruggdose,gwhichgfactorgisgappropriategtogconsiderg
whengdecidinggwhengtoggivegagdrug?ga.gThegpatient‘sgabilitygtogswallowg
b. Thegpatient‘sgheightg
c. Thegpatient‘sglastgmealg
d. Thegpatient‘sgallergiesg
, ANS:gCg
Thegnursegmustgconsidergspecificgpharmacokinetic/pharmacodynamicgdruggpropertiesgthatgma
ygbegaffectedgbygthegtiminggofgtheglastgmeal.gThegpatient‘sgabilitygtogswallow,gheight,gandgaller
giesgaregnotgfactorsgtogconsidergregardinggthegtiminggofgthegdrug‘sgadministration.g
g
DIF:gCognitivegLevel:gUnderstandingg(Comprehension)g
TOP:gNursinggProcess:gAssessmentg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gManagementgofgCareg
g
8. Thegnursegisgperforminggangassessmentgofgagnewlygadmittedgpatient.gWhichgisgangexamplegofg
subjectivegdata?g
a. Weightg155gpoundsg
b. Pulseg72gbeats/minuteg
c. Thegpatientgreportsgthatghegusesgthegherbalgproductgginkgog
d. Thegpatient‘sgcompletegbloodgcountgresultsg
ANS:gCg
Subjectivegdatagincludeginformationgsharedgthroughgthegspokengwordgbyganygreliablegsource,gs
uchgasgthegpatient.gObjectivegdatagmaygbegdefinedgasganyginformationggatheredgthroughgthegse
nsesgorgthatgwhichgisgseen,gheard,gfelt,gorgsmelled.gAgpatient‘sgpulse,gweight,gandglaboratorygte
stsgaregallgexamplesgofgobjectivegdata.g
g
DIF:gCognitivegLevel:gUnderstandingg(Comprehension)g
TOP:gNursinggProcess:gAssessmentg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gManagementgofgCareg
g
MULTIPLEgRESPONSEg
g
1.gWhenggivinggmedications,gthegnursegwillgfollowgthegrightsgofgmedicationgadministration.gTh
egrightsgincludegthegrightgdocumentation,gthegrightgreason,gthegrightgresponse,gandgthegpatie
nt‘sgrightgtogrefuse.gWhichgofgthesegaregadditionalgrights?g(Selectgallgthatgapply.)ga.gRightgdr
ugg
b. Rightgrouteg
c. Rightgdoseg
d. Rightgdiagnosisg
e. Rightgtimeg
f. Rightgpatientg
ANS:gA,gB,gC,gE,gFg
Additionalgrightsgofgmedicationgadministrationgmustgalwaysgincludegthegrightgdrug,grightgdose,
grightgtime,grightgroute,gandgrightgpatient.gThegrightgdiagnosisgisgincorrect.g
g
DIF:gCognitivegLevel:gRememberingg(Knowledge)g
TOP:gNursinggProcess:gImplementationg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gSafetygandgInfectiongControlg
g
OTHERg
g
1.gPlacegthegphasesgofgthegnursinggprocessgingthegcorrectgorder,gwithg1gasgthegfirstgphasegandg5gasgt
heglastgphase.g
g
, a.gPlanningg
b.gEvaluationg
c.gAssessmentg
d.gImplementationg
e.gHumangneedsgstatementg
g
ANS:g
C,gE,gA,gD,gBg
g
Thegnursinggprocessgisgangongoinggprocessgthatgbeginsgwithgassessinggandgcontinuesgwithghum
angneedsgstatement,gplanning,gimplementing,gandgevaluating.g
g
DIF:gCognitivegLevel:gApplyingg(Application)g TOP:gNursinggProcess:gGeneralg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gManagementgofgCareg
singgProcess,g10thgEditiong g
g
MULTIPLEgCHOICEg
g
1. Thegnursegisgdevelopinggaghumangneedsgstatementgforgagpatientgwhoghasgagnewgdiagnosisgofgh
eartgfailure.gIdentificationgofghumangneedsgstatementsgoccurgwithgwhichgofgthesegactivities?ga.
gCollectiongofgpatientgdatag
b. Administeringginterventionsg
c. Decidinggongpatientgoutcomesg
d. Documentinggthegpatient‘sgbehaviorg
ANS:gAg
Identificationgofghumangneedsgoccursgwithgthegcollectiongofgpatientgdata.g
g
DIF:gCognitivegLevel:gUnderstandingg(Comprehension)g
TOP:gNursinggProcess:gHumangNeedsgStatementg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gManagementgofgCareg
g
2. Thegpatientgisgtogreceivegoralgguaifenesingtwicegagday.gToday,gthegnursegwasgbusygandggavegt
hegmedicationg2ghoursgaftergthegscheduledgdosegwasgdue.gWhatgtypegofgproblemgdoesgthisgrep
resent?g
a. ―Rightgtime‖g
b. ―Rightgdose‖g
c. ―Rightgroute‖g
d. ―Rightgmedication‖g
ANS:gAg
―Rightgtime‖gisgcorrectgbecausegthegmedicationgwasggivengmoregthang30gminutesgaftergthegsch
eduledgdosegwasgdue.g―Dose‖gisgincorrectgbecausegthegdosegisgnotgrelatedgtogthegtimegthegmed
icationgadministrationgisgscheduled.g―Route‖gisgincorrectgbecausegthegroutegisgnotgaffected.g―
Medication‖gisgincorrectgbecausegthegmedicationgorderedgwillgnotgchange.g
g
DIF:gCognitivegLevel:gApplyingg(Application)g
TOP:gNursinggProcess:gImplementationg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gSafetygandgInfectiongControlg
g
3. Thegnurseghasgbeengmonitoringgthegpatient‘sgprogressgongagnewgdruggregimengsincegthegfirstgd
osegandgdocumentinggthegpatient‘sgtherapeuticgresponsegtogthegmedication.gWhichgphasegofgth
egnursinggprocessgdogthesegactionsgillustrate?ga.gHumangneedsgstatementg
b. Planningg
c. Implementationg
d. Evaluationg
ANS:gDg
Monitoringgthegpatient‘sgprogress,gincludinggthegpatient‘sgresponsegtogthegmedication,gisgpartgo
fgthegevaluationgphase.gPlanning,gimplementation,gandghumangneedsgstatementgaregnotgillustrat
edgbygthisgexample.g
g
DIF:gggCognitivegLevel:gUnderstandingg(Comprehension)g TOP:gNursinggProcess:gEvaluationg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gManagementgofgCareg
g
4. Thegnursegisgassignedgtogagpatientgwhogisgnewlygdiagnosedgwithgtypeg1gdiabetesgmellitus.g
, Whichgstatementgbestgillustratesgangoutcomegcriteriongforgthisgpatient?g
a.gThegpatientgwillgfollowginstructions.g
b. Thegpatientgwillgnotgexperiencegcomplications.g
c. Thegpatientgwillgadheregtogthegnewginsulingtreatmentgregimen.g
d. Thegpatientgwillgdemonstrategcorrectgbloodgglucosegtestinggtechnique.g
ANS:gDg
―Demonstratinggcorrectgbloodgglucosegtestinggtechnique‖gisgagspecificgandgmeasurablegoutco
megcriterion.g―Followingginstructions‖gandg―notgexperiencinggcomplications‖garegnotgspecif
icgcriteria.g―Adheringgtognewgregimen‖gwouldgbegdifficultgtogmeasure.g
g
DIF:gCognitivegLevel:gApplyingg(Application)g
TOP:gNursinggProcess:gPlanninggMSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gMana
gementgofgCareg
g
5. Whichgactivitygbestgreflectsgthegimplementationgphasegofgthegnursinggprocessgforgthegpatientg
whogisgnewlygdiagnosedgwithghypertension?g
a. Providinggeducationgongkeepinggagjournalgofgbloodgpressuregreadingsg
b. Settingggoalsgandgoutcomegcriteriagwithgthegpatient‘sginputg
c. Recordinggagdrugghistorygregardinggover-the-countergmedicationsgusedgatghomeg
d. Formulatingghumangneedsgstatementsgregardinggdeficientgknowledgegrelatedgtogthegnewgtre
atmentgregimeng
ANS:gAg
Educationgisganginterventiongthatgoccursgduringgthegimplementationgphase.gSettingggoalsgandgo
utcomesgreflectsgthegplanninggphase.gRecordinggagdrugghistorygreflectsgthegassessmentgphase.g
Formulatingghumangneedsgstatementsgreflectsganalysisgofgdatagasgpartgofgplanning.g
g
DIF:gCognitivegLevel:gApplyingg(Application)g
TOP:gNursinggProcess:gImplementationg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gManagementgofgCareg
g
6. Thegmedicationgordergreads,g―Givegondansetrong4gmg,g30gminutesgbeforegbeginninggchemot
herapygtogpreventgnausea.‖gThegnursegnotesgthatgthegroutegisgmissinggfromgthegorder.gWhatgisgt
hegnurse‘sgbestgaction?g
a. Givegthegmedicationgintravenouslygbecausegthegpatientgmightgvomit.g
b. Givegthegmedicationgorallygbecausegthegtabletsgaregavailableging4-mggdoses.g
c. Contactgthegprescribergtogclarifygthegroutegofgthegmedicationgordered.g
d. Holdgthegmedicationguntilgthegprescribergreturnsgtogmakegrounds.g
ANS:gCg
Agcompletegmedicationgordergincludesgthegroutegofgadministration.gIfgagmedicationgordergdoesg
notgincludegthegroute,gthegnursegmustgaskgthegprescribergtogclarifygit.gThegintravenousgandgoralg
routesgaregnotginterchangeable.gHoldinggthegmedicationguntilgthegprescribergreturnsgwouldgmea
ngthatgthegpatientgwouldgnotgreceivegagneededgmedication.g
g
DIF:gCognitivegLevel:gApplyingg(Application)g
TOP:gNursinggProcess:gImplementationg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gManagementgofgCareg
7. Whengthegnursegconsidersgthegtiminggofgagdruggdose,gwhichgfactorgisgappropriategtogconsiderg
whengdecidinggwhengtoggivegagdrug?ga.gThegpatient‘sgabilitygtogswallowg
b. Thegpatient‘sgheightg
c. Thegpatient‘sglastgmealg
d. Thegpatient‘sgallergiesg
, ANS:gCg
Thegnursegmustgconsidergspecificgpharmacokinetic/pharmacodynamicgdruggpropertiesgthatgma
ygbegaffectedgbygthegtiminggofgtheglastgmeal.gThegpatient‘sgabilitygtogswallow,gheight,gandgaller
giesgaregnotgfactorsgtogconsidergregardinggthegtiminggofgthegdrug‘sgadministration.g
g
DIF:gCognitivegLevel:gUnderstandingg(Comprehension)g
TOP:gNursinggProcess:gAssessmentg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gManagementgofgCareg
g
8. Thegnursegisgperforminggangassessmentgofgagnewlygadmittedgpatient.gWhichgisgangexamplegofg
subjectivegdata?g
a. Weightg155gpoundsg
b. Pulseg72gbeats/minuteg
c. Thegpatientgreportsgthatghegusesgthegherbalgproductgginkgog
d. Thegpatient‘sgcompletegbloodgcountgresultsg
ANS:gCg
Subjectivegdatagincludeginformationgsharedgthroughgthegspokengwordgbyganygreliablegsource,gs
uchgasgthegpatient.gObjectivegdatagmaygbegdefinedgasganyginformationggatheredgthroughgthegse
nsesgorgthatgwhichgisgseen,gheard,gfelt,gorgsmelled.gAgpatient‘sgpulse,gweight,gandglaboratorygte
stsgaregallgexamplesgofgobjectivegdata.g
g
DIF:gCognitivegLevel:gUnderstandingg(Comprehension)g
TOP:gNursinggProcess:gAssessmentg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gManagementgofgCareg
g
MULTIPLEgRESPONSEg
g
1.gWhenggivinggmedications,gthegnursegwillgfollowgthegrightsgofgmedicationgadministration.gTh
egrightsgincludegthegrightgdocumentation,gthegrightgreason,gthegrightgresponse,gandgthegpatie
nt‘sgrightgtogrefuse.gWhichgofgthesegaregadditionalgrights?g(Selectgallgthatgapply.)ga.gRightgdr
ugg
b. Rightgrouteg
c. Rightgdoseg
d. Rightgdiagnosisg
e. Rightgtimeg
f. Rightgpatientg
ANS:gA,gB,gC,gE,gFg
Additionalgrightsgofgmedicationgadministrationgmustgalwaysgincludegthegrightgdrug,grightgdose,
grightgtime,grightgroute,gandgrightgpatient.gThegrightgdiagnosisgisgincorrect.g
g
DIF:gCognitivegLevel:gRememberingg(Knowledge)g
TOP:gNursinggProcess:gImplementationg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gSafetygandgInfectiongControlg
g
OTHERg
g
1.gPlacegthegphasesgofgthegnursinggprocessgingthegcorrectgorder,gwithg1gasgthegfirstgphasegandg5gasgt
heglastgphase.g
g
, a.gPlanningg
b.gEvaluationg
c.gAssessmentg
d.gImplementationg
e.gHumangneedsgstatementg
g
ANS:g
C,gE,gA,gD,gBg
g
Thegnursinggprocessgisgangongoinggprocessgthatgbeginsgwithgassessinggandgcontinuesgwithghum
angneedsgstatement,gplanning,gimplementing,gandgevaluating.g
g
DIF:gCognitivegLevel:gApplyingg(Application)g TOP:gNursinggProcess:gGeneralg
MSC:gNCLEX:gSafegandgEffectivegCaregEnvironment:gManagementgofgCareg
