Full Test Bank
, Chapter 01: The Nursing Process and Drug Therapy
MULTIPLE CHOICE
1. The RN is writing a nursing diagnosis for a plan of care for a client who has been newly
diagnosed with type 2 diabetes. Which statement reflects the correct format for a nursing
diagnosis?
a. Anxiety
b. Anxiety related to new drug therapy
c. Anxiety related to anxious feelings about drug therapy, as evidenced by
statements such as ―I‘m upset about having to test my blood sugars.‖
d. Anxiety related to new drug therapy, as evidenced by statements such as
―I‘m upset about having to test my blood sugars.‖
CORRECT ANS: D
Formulation of nursing diagnoses is usually a three-step process. ―Anxiety‖ is missing the
―related to‖ and ―as evidenced by‖ portions of defining characteristics. ―Anxiety related to
new drug therapy‖ is missing the ―as evidenced by‖ portion of defining characteristics.
The statement beginning ―Anxiety related to anxious feelings‖ is incorrect because the
―related to‖ section is simply a restatement of the problem ―anxiety,‖ not a separate factor
related to the response.
DIF: COGNITIVE LEVEL: Understanding
(Comprehension) TOP: NURSING PROCESS: Nursing
Diagnosis
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
2. The client is to receive oral guaifenesin (Mucinex) twice a day. Today, the RN was busy and
gave the medication 2 hours after the scheduled dose was due. What type of problem does this
represent?
a. ―Right time‖
b. ―Right dose‖
c. ―Right route‖
d. ―Right medication‖
CORRECT ANS: A
―Right time‖ is correct because the medication was given more than 30 minutes after the
scheduled dose was due. ―Dose‖ is incorrect because the dose is not related to the time the
medication administration is scheduled. ―Route‖ is incorrect because the route is not affected.
―Medication‖ is incorrect because the medication ordered will not change.
DIF: COGNITIVE LEVEL: Applying
(Application) TOP: NURSING PROCESS:
Implementation
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
, Chapter 01: The Nursing Process and Drug Therapy 5
3. The RN has been monitoring the client‘s progress on a new drug regimen since the first
dose and documenting the client‘s therapeutic response to the medication. Which phase of the
nursing process do these actions illustrate?
a. Nursing diagnosis
b. Planning
c. Implementation
d. Evaluation
CORRECT ANS: D
Monitoring the client‘s progress, including the client‘s response to the medication, is part of
the evaluation phase. Planning, implementation, and nursing diagnosis are not illustrated by
this example.
DIF: COGNITIVE LEVEL: Understanding
(Comprehension) TOP: NURSING PROCESS: Evaluation
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
4. The RN is assigned to a client who is newly diagnosed with type 1 diabetes mellitus. Which
statement best illustrates an outcome criterion for this client?
a. The client will follow instructions.
b. The client will not experience complications.
c. The client will adhere to the new insulin treatment regimen.
d. The client will demonstrate correct blood glucose testing technique.
CORRECT ANS: D
―Demonstrating correct blood glucose testing technique‖ is a specific and measurable
outcome criterion. ―Following instructions‖ and ―not experiencing complications‖ are not
specific criteria.
―Adhering to new regimen‖ would be difficult to measure.
DIF: COGNITIVE LEVEL: Applying
(Application) TOP: NURSING PROCESS: Planning
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
5. Which activity best reflects the implementation phase of the nursing process for the client
who is newly diagnosed with hypertension?
a. Providing education on keeping a journal of blood pressure readings
b. Setting goals and outcome criteria with the client‘s input
c. Recording a drug history regarding over-the-counter medications used at home
d. Formulating nursing diagnoses regarding deficient knowledge related to the
new treatment regimen
CORRECT ANS: A
Education is an intervention that occurs during the implementation phase. Setting goals and
outcomes reflects the planning phase. Recording a drug history reflects the assessment
phase. Formulating nursing diagnoses reflects analysis of data as part of planning.
DIF: COGNITIVE LEVEL: Applying
(Application) TOP: NURSING PROCESS:
Implementation
, MSC: NCLEX: Safe and Effective Care Environment: Management of Care
, Chapter 01: The Nursing Process and Drug Therapy
MULTIPLE CHOICE
1. The RN is writing a nursing diagnosis for a plan of care for a client who has been newly
diagnosed with type 2 diabetes. Which statement reflects the correct format for a nursing
diagnosis?
a. Anxiety
b. Anxiety related to new drug therapy
c. Anxiety related to anxious feelings about drug therapy, as evidenced by
statements such as ―I‘m upset about having to test my blood sugars.‖
d. Anxiety related to new drug therapy, as evidenced by statements such as
―I‘m upset about having to test my blood sugars.‖
CORRECT ANS: D
Formulation of nursing diagnoses is usually a three-step process. ―Anxiety‖ is missing the
―related to‖ and ―as evidenced by‖ portions of defining characteristics. ―Anxiety related to
new drug therapy‖ is missing the ―as evidenced by‖ portion of defining characteristics.
The statement beginning ―Anxiety related to anxious feelings‖ is incorrect because the
―related to‖ section is simply a restatement of the problem ―anxiety,‖ not a separate factor
related to the response.
DIF: COGNITIVE LEVEL: Understanding
(Comprehension) TOP: NURSING PROCESS: Nursing
Diagnosis
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
2. The client is to receive oral guaifenesin (Mucinex) twice a day. Today, the RN was busy and
gave the medication 2 hours after the scheduled dose was due. What type of problem does this
represent?
a. ―Right time‖
b. ―Right dose‖
c. ―Right route‖
d. ―Right medication‖
CORRECT ANS: A
―Right time‖ is correct because the medication was given more than 30 minutes after the
scheduled dose was due. ―Dose‖ is incorrect because the dose is not related to the time the
medication administration is scheduled. ―Route‖ is incorrect because the route is not affected.
―Medication‖ is incorrect because the medication ordered will not change.
DIF: COGNITIVE LEVEL: Applying
(Application) TOP: NURSING PROCESS:
Implementation
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
, Chapter 01: The Nursing Process and Drug Therapy 5
3. The RN has been monitoring the client‘s progress on a new drug regimen since the first
dose and documenting the client‘s therapeutic response to the medication. Which phase of the
nursing process do these actions illustrate?
a. Nursing diagnosis
b. Planning
c. Implementation
d. Evaluation
CORRECT ANS: D
Monitoring the client‘s progress, including the client‘s response to the medication, is part of
the evaluation phase. Planning, implementation, and nursing diagnosis are not illustrated by
this example.
DIF: COGNITIVE LEVEL: Understanding
(Comprehension) TOP: NURSING PROCESS: Evaluation
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
4. The RN is assigned to a client who is newly diagnosed with type 1 diabetes mellitus. Which
statement best illustrates an outcome criterion for this client?
a. The client will follow instructions.
b. The client will not experience complications.
c. The client will adhere to the new insulin treatment regimen.
d. The client will demonstrate correct blood glucose testing technique.
CORRECT ANS: D
―Demonstrating correct blood glucose testing technique‖ is a specific and measurable
outcome criterion. ―Following instructions‖ and ―not experiencing complications‖ are not
specific criteria.
―Adhering to new regimen‖ would be difficult to measure.
DIF: COGNITIVE LEVEL: Applying
(Application) TOP: NURSING PROCESS: Planning
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
5. Which activity best reflects the implementation phase of the nursing process for the client
who is newly diagnosed with hypertension?
a. Providing education on keeping a journal of blood pressure readings
b. Setting goals and outcome criteria with the client‘s input
c. Recording a drug history regarding over-the-counter medications used at home
d. Formulating nursing diagnoses regarding deficient knowledge related to the
new treatment regimen
CORRECT ANS: A
Education is an intervention that occurs during the implementation phase. Setting goals and
outcomes reflects the planning phase. Recording a drug history reflects the assessment
phase. Formulating nursing diagnoses reflects analysis of data as part of planning.
DIF: COGNITIVE LEVEL: Applying
(Application) TOP: NURSING PROCESS:
Implementation
, MSC: NCLEX: Safe and Effective Care Environment: Management of Care
