x
lOMoAR x x
cPSD| 3013804
, x
2. The patient is to receive oral furosemide (Lasix) every day; however, because the patient is unable to sw
x x x x x x x x x x x x x x x x x
xmedication orally, as ordered. The nurse needs to contact the physician. What type of problem is this?
x x x x x x x x x x x x x x x x
a. A ―right time‖ problem
x x x
b. A ―right dose‖ problem
x x x
c. A ―right route‖ problem
x x x
d. A ―right medication‖ problem
x x x
ANS: C x
This is a ―right route‖ problem: the nurse cannot assume the route and must clarify the route with the p
x x x x x x x x x x x x x x x x x x x
time‖ problem because the ordered frequency has not changed. This is not a ―right dose‖ problem beca
x x x x x x x x x x x x x x x x x
an inability to swallow. This is not a ―right medication‖ problem because the medication ordered will n
x x x x x x x x x x x x x x x x x
DIF: Cognitive Level: Application x x
3. The nurse has been monitoring the patient‘s progress on his new drug regimen since the first dose and h
x x x x x x x x x x x x x x x x x x
xof possible adverse effects. What nursing process phase is the nurse practising?
x x x x x x x x x x x
a. Planning
b. Evaluation
c. Implementation
d. Nursing diagnosis x
ANS: B x
Monitoring the patient‘s progress is part of the evaluation phase. Planning, implementation, and nursing
x x x x x x x x x x x x x
illustrated by this example.
x x x x
DIF: Cognitive Level: Application x x
4. The nurse is caring for a patient who has been newly diagnosed with type 1 diabetes mellitus. Which sta
x x x x x x x x x x x x x x x x x x
xoutcome criterion for this patient? x x x x
a. The patient will follow instructions.
x x x x
b. The patient will not experience complications.
x x x x x
c. The patient adheres to the new insulin treatment regimen.
x x x x x x x x
d. The patient demonstrates safe insulin self-administration technique.
x x x x x x
ANS: D x
Having the patient demonstrate safe insulin self-administration technique is a specific and measurable o
x x x x x x x x x x x x x
instructions and avoiding complications are not specific criteria. Adherence to the new insulin treatme
x x x x x x x x x x x x x x
and would be difficult to measure.
x x x x x x
DIF: Cognitive Level: Application x x
5. Which activity best reflects the implementation phase of the nursing process for the patient who is newl
x x x x x x x x x x x x x x x x
xdiabetes mellitus? x
a. Providing education regarding self-injection technique x x x x
b. Setting goals and outcome criteria with the patient‘s input
x x x x x x x x
c. Recording a history of over-the-counter medications used at home x x x x x x x x
d. Formulating nursing diagnoses regarding knowledge deficits related to the new x x x x x x x x x
treatment regimen
x x
ANS: A x
Education is an intervention that occurs during the implementation phase. Setting goals and outcome cr
x x x x x x x x x x x x x x
phase. Recording a drug history reflects the assessment phase. Formulating nursing diagnoses regardin
x x x x x x x x x x x x x
, x
reflects analysis of data as part of the planning phase.
x x x x x x x x x
DIF: Cognitive Level: Analysis
x x
Copyright © 2021, Elsevier Inc. All rights reserved.
x x x x x x x
, x
6. The nurse is working during a very busy night shift, and the health care provider has just given the nurs
x x x x x x x x x x x x x x x x x x x
the telephone, but the nurse does not recall the route. What is the best way for the nurse to avoid medic
x x x x x x x x x x x x x x x x x x x x x
a. Recopy the order neatly on the order sheet, with the most common route indicated
x x x x x x x x x x x x x
b. Consult with the pharmacist for clarification about the most common route
x x x x x x x x x x
c. Call the health care provider to clarify the route of administration
x x x x x x x x x x
d. Withhold the drug until the health care provider visits the patient
x x x x x x x x x x
ANS: C x
If a medication order does not include the route, the nurse must ask the health care provider to clarify it.
x x x x x x x x x x x x x x x x x x x
administration.
x
DIF: Cognitive Level: Application | Cognitive Level: Analysis
x x x x x x
7. Which constitutes the traditional Five Rights of medication administration?
x x x x x x x x
a. Right drug, right route, right dose, right time, and right patient
x x x x x x x x x x
b. Right drug, the right effect, the right route, the right time, and the right patient
x x x x x x x x x x x x x x
c. Right patient, right strength, right diagnosis, right drug, and right route
x x x x x x x x x x
d. Right patient, right diagnosis, right drug, right route, and right time
x x x x x x x x x x
ANS: A x
The traditional Five Rights of medication administration were considered to be Right drug, Right route,
x x x x x x x x x x x x x x
Right patient. Right effect, right strength, and right diagnosis are not part of the traditional Five Rights
x x x x x x x x x x x x x x x x x
DIF: Cognitive Level: Comprehension x x
8. What correctly describes the nursing process?
x x x x x
a. Diagnosing, planning, assessing, implementing, and finally evaluating
x x x x x x
b. Assessing, then diagnosing, implementing, and ending with evaluating
x x x x x x x
c. A linear direction that begins with assessing and continues through diagnosing,
x x x x x x x x x x
planning, and finally implementing
x x x x
d. An ongoing process that begins with assessing and continues with diagnosing,
x x x x x x x x x x
planning, implementing, and evaluating
x x x x
ANS: D x
The nursing process is an ongoing, flexible, adaptable, and adjustable five-step process that begins with
x x x x x x x x x x x x x x
through diagnosing, planning, implementing, and finally evaluating, which may then lead back to any
x x x x x x x x x x x x x x x
DIF: Cognitive Level: Application x x
9. When the nurse is considering the timing of a drug dose, which is most important to assess?
x x x x x x x x x x x x x x x x
a. The patient‘s identification x x
b. The patient‘s weight x x
c. The patient‘s last meal x x x
d. Any drug or food allergies x x x x
ANS: C x
The pharmacokinetic and pharmacodynamic properties of the drug need to be assessed with regard to a
x x x x x x x x x x x x x x x
compatibility issues. The patient‘s identification, weight, and drug or food allergies are not affected by
x x x x x x x x x x x x x x x
DIF: Cognitive Level: Application x x
10. The nurse is writing nursing diagnoses for a plan of care. Which reflects the correct format for her nurs
x x x x x x x x x x x x x x x x x x
a. Anxiety
b. Anxiety related to new drug therapy x x x x x
c. Anxiety related to anxious feelings about drug therapy, as evidenced by
x x x x x x x x x x
statements such as ―I‘m upset about having to give myself shots‖
x x x x x x x x x x x
d. Anxiety related to new drug therapy, as evidenced by statements such as ―I‘m
x x x x x x x x x x x x
upset about having to give myself shots‖
x x x x x x x
ANS: D x
Formulation of nursing diagnoses is usually a three-step process. The only complete answer is ―Anxiet
x x x x x x x x x x x x x x
lOMoAR x x
cPSD| 3013804
, x
2. The patient is to receive oral furosemide (Lasix) every day; however, because the patient is unable to sw
x x x x x x x x x x x x x x x x x
xmedication orally, as ordered. The nurse needs to contact the physician. What type of problem is this?
x x x x x x x x x x x x x x x x
a. A ―right time‖ problem
x x x
b. A ―right dose‖ problem
x x x
c. A ―right route‖ problem
x x x
d. A ―right medication‖ problem
x x x
ANS: C x
This is a ―right route‖ problem: the nurse cannot assume the route and must clarify the route with the p
x x x x x x x x x x x x x x x x x x x
time‖ problem because the ordered frequency has not changed. This is not a ―right dose‖ problem beca
x x x x x x x x x x x x x x x x x
an inability to swallow. This is not a ―right medication‖ problem because the medication ordered will n
x x x x x x x x x x x x x x x x x
DIF: Cognitive Level: Application x x
3. The nurse has been monitoring the patient‘s progress on his new drug regimen since the first dose and h
x x x x x x x x x x x x x x x x x x
xof possible adverse effects. What nursing process phase is the nurse practising?
x x x x x x x x x x x
a. Planning
b. Evaluation
c. Implementation
d. Nursing diagnosis x
ANS: B x
Monitoring the patient‘s progress is part of the evaluation phase. Planning, implementation, and nursing
x x x x x x x x x x x x x
illustrated by this example.
x x x x
DIF: Cognitive Level: Application x x
4. The nurse is caring for a patient who has been newly diagnosed with type 1 diabetes mellitus. Which sta
x x x x x x x x x x x x x x x x x x
xoutcome criterion for this patient? x x x x
a. The patient will follow instructions.
x x x x
b. The patient will not experience complications.
x x x x x
c. The patient adheres to the new insulin treatment regimen.
x x x x x x x x
d. The patient demonstrates safe insulin self-administration technique.
x x x x x x
ANS: D x
Having the patient demonstrate safe insulin self-administration technique is a specific and measurable o
x x x x x x x x x x x x x
instructions and avoiding complications are not specific criteria. Adherence to the new insulin treatme
x x x x x x x x x x x x x x
and would be difficult to measure.
x x x x x x
DIF: Cognitive Level: Application x x
5. Which activity best reflects the implementation phase of the nursing process for the patient who is newl
x x x x x x x x x x x x x x x x
xdiabetes mellitus? x
a. Providing education regarding self-injection technique x x x x
b. Setting goals and outcome criteria with the patient‘s input
x x x x x x x x
c. Recording a history of over-the-counter medications used at home x x x x x x x x
d. Formulating nursing diagnoses regarding knowledge deficits related to the new x x x x x x x x x
treatment regimen
x x
ANS: A x
Education is an intervention that occurs during the implementation phase. Setting goals and outcome cr
x x x x x x x x x x x x x x
phase. Recording a drug history reflects the assessment phase. Formulating nursing diagnoses regardin
x x x x x x x x x x x x x
, x
reflects analysis of data as part of the planning phase.
x x x x x x x x x
DIF: Cognitive Level: Analysis
x x
Copyright © 2021, Elsevier Inc. All rights reserved.
x x x x x x x
, x
6. The nurse is working during a very busy night shift, and the health care provider has just given the nurs
x x x x x x x x x x x x x x x x x x x
the telephone, but the nurse does not recall the route. What is the best way for the nurse to avoid medic
x x x x x x x x x x x x x x x x x x x x x
a. Recopy the order neatly on the order sheet, with the most common route indicated
x x x x x x x x x x x x x
b. Consult with the pharmacist for clarification about the most common route
x x x x x x x x x x
c. Call the health care provider to clarify the route of administration
x x x x x x x x x x
d. Withhold the drug until the health care provider visits the patient
x x x x x x x x x x
ANS: C x
If a medication order does not include the route, the nurse must ask the health care provider to clarify it.
x x x x x x x x x x x x x x x x x x x
administration.
x
DIF: Cognitive Level: Application | Cognitive Level: Analysis
x x x x x x
7. Which constitutes the traditional Five Rights of medication administration?
x x x x x x x x
a. Right drug, right route, right dose, right time, and right patient
x x x x x x x x x x
b. Right drug, the right effect, the right route, the right time, and the right patient
x x x x x x x x x x x x x x
c. Right patient, right strength, right diagnosis, right drug, and right route
x x x x x x x x x x
d. Right patient, right diagnosis, right drug, right route, and right time
x x x x x x x x x x
ANS: A x
The traditional Five Rights of medication administration were considered to be Right drug, Right route,
x x x x x x x x x x x x x x
Right patient. Right effect, right strength, and right diagnosis are not part of the traditional Five Rights
x x x x x x x x x x x x x x x x x
DIF: Cognitive Level: Comprehension x x
8. What correctly describes the nursing process?
x x x x x
a. Diagnosing, planning, assessing, implementing, and finally evaluating
x x x x x x
b. Assessing, then diagnosing, implementing, and ending with evaluating
x x x x x x x
c. A linear direction that begins with assessing and continues through diagnosing,
x x x x x x x x x x
planning, and finally implementing
x x x x
d. An ongoing process that begins with assessing and continues with diagnosing,
x x x x x x x x x x
planning, implementing, and evaluating
x x x x
ANS: D x
The nursing process is an ongoing, flexible, adaptable, and adjustable five-step process that begins with
x x x x x x x x x x x x x x
through diagnosing, planning, implementing, and finally evaluating, which may then lead back to any
x x x x x x x x x x x x x x x
DIF: Cognitive Level: Application x x
9. When the nurse is considering the timing of a drug dose, which is most important to assess?
x x x x x x x x x x x x x x x x
a. The patient‘s identification x x
b. The patient‘s weight x x
c. The patient‘s last meal x x x
d. Any drug or food allergies x x x x
ANS: C x
The pharmacokinetic and pharmacodynamic properties of the drug need to be assessed with regard to a
x x x x x x x x x x x x x x x
compatibility issues. The patient‘s identification, weight, and drug or food allergies are not affected by
x x x x x x x x x x x x x x x
DIF: Cognitive Level: Application x x
10. The nurse is writing nursing diagnoses for a plan of care. Which reflects the correct format for her nurs
x x x x x x x x x x x x x x x x x x
a. Anxiety
b. Anxiety related to new drug therapy x x x x x
c. Anxiety related to anxious feelings about drug therapy, as evidenced by
x x x x x x x x x x
statements such as ―I‘m upset about having to give myself shots‖
x x x x x x x x x x x
d. Anxiety related to new drug therapy, as evidenced by statements such as ―I‘m
x x x x x x x x x x x x
upset about having to give myself shots‖
x x x x x x x
ANS: D x
Formulation of nursing diagnoses is usually a three-step process. The only complete answer is ―Anxiet
x x x x x x x x x x x x x x
