Verified Answers | Complete Q&A Guide | A+ Graded
1. The nurse is preparing to administer a medication and reviews the patient's chart for drug allergies,
serum creatinine, and blood urea nitrogen (BUN) levels. The nurse's actions are reflective of which step
of the Clinical Judgment Measurement Model (NCJMM)?
A) Recognize Cues (Assessment)
B) Analyze Cues & Prioritize Hypotheses (Analysis)
C) Generate Solutions (Planning)
D) Take Action (Implementation)
Answer: A
Explanation: Recognizing cues (assessment) involves gathering subjective and objective information
about the patient and the medication. Laboratory values from the patient's chart are considered
collection of objective data. This is the foundational first step of the nursing process and clinical
judgment.
2. All of the following would be considered subjective data, EXCEPT:
A) Patientreported health history
B) Patientreported signs and symptoms of their illness
C) Financial barriers reported by the patient's caregiver
D) Vital signs obtained from the medical record
Answer: D
,Explanation: Subjective data is based on what patients or family members communicate to the nurse.
Patientreported health history, signs and symptoms, and caregiverreported barriers are subjective. Vital
signs obtained from the medical record are objective data. Differentiating subjective from objective data
is critical for accurate nursing assessment.
3. The nursing process is a fivestep decisionmaking approach that includes all of the following steps,
EXCEPT:
A) Assessment
B) Patient problem
C) Planning
D) Right drug
Answer: D
Explanation: The nursing process consists of five steps: assessment, patient problem (diagnosis),
planning, implementation, and evaluation. "Right drug" is one of the "Six Rights" of medication
administration, not a step in the nursing process. This is a common NCLEX trick—don't confuse the
nursing process with medication administration rights.
4. A nurse is caring for a patient who is receiving a newly prescribed medication. Which action best
demonstrates the evaluation phase of the nursing process?
A) Asking the patient about their medication history
B) Setting a goal to reduce pain to 3/10 within 1 hour
C) Administering the medication via the prescribed route
D) Assessing the patient's response 30 minutes after administration
,Answer: D
Explanation: Evaluation involves assessing the patient's response to the medication and determining if
goals have been met. Asking about history is assessment, setting goals is planning, and administering is
implementation.
5. The nurse is using data collected to define a set of interventions to achieve the most desirable
outcomes. Which step of the nursing process is the nurse applying?
A) Recognizing cues (assessment)
B) Analyze cues and prioritize hypothesis (analysis)
C) Generate solutions (planning)
D) Take action (nursing interventions)
Answer: C
Explanation: When generating solutions (planning), the nurse identifies expected outcomes and defines
interventions to achieve the most desirable outcomes. Assessment is gathering cues; analysis involves
organizing and ranking patient problems; implementation (taking action) is executing the interventions.
6. A patient is receiving a drug that is known to be highly proteinbound. Which finding would the nurse
expect if the patient has low serum albumin levels?
A) Reduced drug effect
B) Increased risk of drug toxicity
C) Decreased drug absorption
D) Faster drug excretion
, Answer: B
Explanation: Low serum albumin levels mean fewer proteinbinding sites are available for the drug. This
results in more unbound (free) drug circulating, which can lead to increased pharmacologic effect and
risk of toxicity. Highly proteinbound drugs compete for binding sites; when albumin is low, free drug
concentration rises.
7. A patient is prescribed a medication that undergoes extensive firstpass metabolism. The nurse
anticipates that the prescriber will:
A) Increase the oral dose
B) Administer the drug via the IV route
C) Decrease the oral dose
D) Administer the drug with food
Answer: B
Explanation: Firstpass metabolism refers to the extensive metabolism of a drug by the liver before it
reaches systemic circulation. Drugs with high firstpass effect have reduced bioavailability when given
orally. Administering the drug via the IV route bypasses firstpass metabolism, allowing more drug to
reach systemic circulation.
8. The nurse is teaching a client about pharmacokinetics. Which statement correctly describes the
difference between absorption and distribution?
A) Absorption is the movement of a drug from the site of administration into the bloodstream;
distribution is the transport of the drug through the bloodstream to tissues