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 preparing to administer a newly prescribed
medication. Which action best demonstrates the Recognize
Cues step of the Clinical Judgment Management Model
(CJMM)?
A. Evaluating whether the medication relieved the patient's
symptoms
B. Reviewing the patient's allergies, current medications, and
vital signs before administration
C. Determining whether the provider should change the
medication dose
D. Teaching the patient about adverse effects after
administration
Correct Answer: B
Rationale: Recognizing cues involves collecting relevant
assessment data before making clinical decisions. Reviewing
allergies, medications, and vital signs helps identify factors that
may affect medication safety.
Question 2
,Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
A nurse reviews the following assessment findings before
administering an antihypertensive medication:
• Blood pressure 86/54 mm Hg
• Reports dizziness when standing
• Serum creatinine elevated from baseline
• Heart rate 52 beats/min
• Scheduled dose due in 15 minutes
Which findings are important cues that require further analysis?
A. Blood pressure 86/54 mm Hg
B. Reports dizziness
C. Elevated serum creatinine
D. Scheduled administration time
E. Heart rate 52 beats/min
Correct Answer: A, B, C, E
Rationale: Hypotension, dizziness, renal impairment, and
bradycardia may indicate increased risk from administering the
medication. The scheduled administration time is not a clinical
cue requiring analysis.
, Question 3
Difficulty: Moderate
Question Type: NGN Clinical Judgment
Question:
A patient prescribed intravenous antibiotics develops itching,
facial swelling, and difficulty breathing shortly after the infusion
begins.
Which nursing action represents the highest-priority
hypothesis?
A. The medication is ineffective.
B. The patient is experiencing an allergic reaction requiring
immediate intervention.
C. The patient is anxious about hospitalization.
D. The infusion is running too slowly.
Correct Answer: B
Rationale: Airway compromise associated with facial swelling
and difficulty breathing suggests a potentially life-threatening
allergic reaction. This hypothesis takes priority because it
threatens patient survival.
Question 4