A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Easy
Question Type: Multiple Choice
Question:
A nurse is reviewing a patient's medication profile before
administering a newly prescribed drug. Which action best
demonstrates the Recognize Cues step of the Clinical Judgment
Measurement Model (CJMM)?
A. Administering the medication as prescribed
B. Reviewing the patient's allergies, vital signs, and laboratory
results
C. Evaluating the patient's response after the medication is
given
D. Developing a plan for managing adverse effects
Correct Answer: B
Rationale: Recognize Cues involves collecting relevant
assessment data before making clinical decisions. Reviewing
allergies, vital signs, and laboratory values helps identify factors
that may influence medication safety.
,Question 2
Difficulty: Moderate
Question Type: Multiple Choice
Question:
A patient receiving an antihypertensive medication reports
dizziness when standing. Which nursing action best reflects the
Analyze Cues phase?
A. Immediately notify the healthcare provider.
B. Determine whether the dizziness is associated with
orthostatic hypotension by comparing blood pressures.
C. Teach the patient to change positions slowly.
D. Document the patient's complaint.
Correct Answer: B
Rationale: Analyze Cues requires interpreting assessment
findings to determine their significance. Comparing sitting and
standing blood pressures helps determine whether orthostatic
hypotension is contributing to the patient's symptoms.
Question 3
Difficulty: Moderate
Question Type: NGN Clinical Judgment
, Question:
A patient receiving intravenous antibiotics develops itching,
facial swelling, and wheezing shortly after the infusion begins.
Which hypothesis should the nurse prioritize?
A. Mild medication intolerance
B. Anxiety related to hospitalization
C. Acute allergic reaction requiring immediate intervention
D. Expected adverse effect of therapy
Correct Answer: C
Rationale: Airway compromise is a life-threatening condition.
Prioritizing an acute allergic reaction allows rapid intervention
to prevent progression to anaphylaxis.
Question 4
Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
Before administering a high-alert medication, which assessment
findings should the nurse recognize as important cues? (Select
all that apply.)
A. Patient allergies
B. Current laboratory values