A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Easy
Question Type: Multiple Choice (MCQ)
Question:
A nurse is preparing to administer a newly prescribed
antihypertensive medication. Before giving the medication, the
nurse reviews the patient's blood pressure, heart rate, current
medications, and allergy history. Which step of the Clinical
Judgment Measurement Model (CJMM) is the nurse
demonstrating?
A. Generate Solutions
B. Recognize Cues
C. Take Action
D. Evaluate Outcomes
Correct Answer: B. Recognize Cues
Rationale: Recognizing cues involves collecting and reviewing
relevant assessment data before making clinical decisions. The
nurse gathers vital signs, medication history, and allergies to
identify information needed for safe medication administration.
,Question 2
Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
A nurse is caring for a patient receiving intravenous opioid
analgesics. Which assessment findings should be recognized as
cues requiring further evaluation?
Select all that apply.
A. Respiratory rate of 8 breaths/minute
B. Oxygen saturation of 89% on room air
C. Pain score decreased from 8/10 to 3/10
D. Difficult to awaken after medication administration
E. Blood pressure 122/76 mm Hg
Correct Answer: A, B, D
Rationale: Respiratory depression, hypoxemia, and excessive
sedation are significant safety concerns with opioids and
require immediate attention. Improved pain control and normal
blood pressure alone are not indicators of opioid toxicity.
Question 3
Difficulty: Moderate
, Question Type: NGN Clinical Judgment
Question:
A patient receiving insulin reports feeling shaky, sweaty, and
dizzy before lunch. The blood glucose level is 52 mg/dL.
Which nursing action should be taken first?
A. Notify the healthcare provider immediately.
B. Administer a rapid-acting carbohydrate.
C. Hold the next insulin dose and reassess in 4 hours.
D. Encourage the patient to ambulate.
Correct Answer: B. Administer a rapid-acting carbohydrate.
Rationale: The patient has symptomatic hypoglycemia.
Immediate treatment with a rapid-acting carbohydrate is the
priority before notifying the provider or adjusting future insulin
doses.
Question 4
Difficulty: Moderate
Question Type: Multiple Choice (MCQ)
Question:
During medication reconciliation, a nurse discovers that a
patient is taking two medications from the same therapeutic
class prescribed by different providers.