Chapter01:TheNursingProcessandDrugTherapy
Lilley:PharmacologyandtheNursingProcess,10thEdition
v
MULTIPLECHOICE
1. Thenurseisdevelopingahumanneedsstatementforapatientwhohasanewdiagnosisofheart
v failure.Identificationofhumanneedsstatementsoccurwithwhichoftheseactivities?
a. Collectionofpatientdata
b. Administeringinterventions
c. Decidingonpatientoutcomes
d. Documentingthepatient‘sbehavior
ANS: A v
Identificationofhumanneedsoccurswiththecollectionofpatientdata.
DIF: CognitiveLevel:Understanding(Comprehension)
TOP: NursingProcess:HumanNeedsStatement
v v
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v
2. Thepatientistoreceiveoralguaifenesintwiceaday.Today,thenursewasbusyandgavethe
medication2hoursafterthescheduleddosewasdue.Whattypeofproblemdoesthisrepresent?
v
a.―Righttime‖
b.―Rightdose‖
c.―Rightroute‖
d.―Rightmedication‖
ANS: A v
―Righttime‖iscorrectbecausethemedicationwasgivenmorethan30minutesafterthescheduled
dosewasdue.―Dose‖isincorrectbecausethedoseisnotrelatedtothetimethemedication
v
administrationisscheduled.―Route‖isincorrectbecausetherouteisnotaffected.
v
―Medication‖isincorrectbecausethemedicationorderedwillnotchange.
DIF: CognitiveLevel:Applying(Application)
TOP: NursingProcess:Implementation
v v
MSC: NCLEX:SafeandEffectiveCareEnvironment:SafetyandInfectionControl
v
3. Thenursehasbeenmonitoringthepatient‘sprogressonanewdrugregimensincethefirstdose
vanddocumentingthepatient‘stherapeuticresponsetothemedication.Whichphaseofthe
nursingprocessdotheseactionsillustrate?
v
a. Humanneedsstatement
b. Planning
c. Implementation
d. Evaluation
ANS: D v
Monitoring the patient‘s progress, including the patient‘s response to the medication, is part of the
v v v v v v v v v v v v v v
evaluation phase. Planning, implementation, and human needs statement are not illustrated bythis
v v v v v v v v v v v v
example.
v
DIF: CognitiveLevel:Understanding(Comprehension)
v TOP: NursingProcess:Evaluation
v
PRIMEXAM.COM
, MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v
4. Thenurseisassignedtoapatientwhoisnewlydiagnosedwithtype1diabetesmellitus.
Whichstatementbestillustratesanoutcomecriterionforthispatient?
v
a.Thepatientwillfollowinstructions.
b.Thepatientwillnotexperiencecomplications.
c.Thepatientwilladheretothenewinsulintreatmentregimen.
d.Thepatientwilldemonstratecorrectbloodglucosetestingtechnique.
ANS: D v
―Demonstratingcorrectbloodglucosetestingtechnique‖isaspecificandmeasurableoutcome
criterion.―Followinginstructions‖and―notexperiencingcomplications‖arenotspecificcriteria.
v
―Adheringtonewregimen‖wouldbedifficulttomeasure.
DIF: CognitiveLevel:Applying(Application) TOP: NursingProcess:Planning
v
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v v
5. Whichactivitybestreflectstheimplementationphaseofthenursingprocessforthepatientwhois
newlydiagnosedwithhypertension?
v
a. Providingeducationonkeepingajournalofbloodpressurereadings
b. Settinggoalsandoutcomecriteriawiththepatient‘sinput
c. Recordingadrughistoryregardingover-the-countermedicationsusedathome
d. Formulatinghumanneedsstatementsregardingdeficientknowledgerelatedtothenew
treatmentregimen
v
ANS: A v
Educationisaninterventionthatoccursduringtheimplementationphase.Settinggoalsandoutcomes
reflectstheplanningphase.Recordingadrughistoryreflectstheassessmentphase.Formulatinghuman
v
needsstatementsreflectsanalysisofdataaspartofplanning.
v
DIF: CognitiveLevel:Applying(Application)
TOP: NursingProcess:Implementation
v v
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v
6. Themedicationorderreads,―Giveondansetron4mg,30minutesbeforebeginning
vchemotherapytopreventnausea.‖Thenursenotesthattherouteismissingfromtheorder.What
isthenurse‘sbestaction?
v
a. Givethemedicationintravenouslybecausethepatientmightvomit.
b. Givethemedicationorallybecausethetabletsareavailablein4-mgdoses.
c. Contacttheprescribertoclarifytherouteofthemedicationordered.
d. Holdthemedicationuntiltheprescriberreturnstomakerounds.
ANS: C v
Acompletemedicationorderincludestherouteofadministration.Ifamedicationorderdoesnot
includetheroute,thenursemustasktheprescribertoclarifyit.Theintravenousandoralroutesare
v
notinterchangeable.Holdingthemedicationuntiltheprescriberreturnswouldmeanthatthe
v
vpatientwouldnotreceiveaneededmedication.
DIF: CognitiveLevel:Applying(Application)
TOP: NursingProcess:Implementation
v v
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v
PRIMEXAM.COM
, 7. Whenthenurseconsidersthetimingofadrugdose,whichfactorisappropriatetoconsiderwhen
decidingwhentogiveadrug?
v
a. Thepatient‘sabilitytoswallow
b. Thepatient‘sheight
c. Thepatient‘slastmeal
d. Thepatient‘sallergies
ANS: Cv
Thenursemust consider specific pharmacokinetic/pharmacodynamic drugpropertiesthat may be
v v v v v v
affected by the timingofthelastmeal. Thepatient‘sability to swallow, height, andallergies arenot
v v v v v v v v v v
factorstoconsiderregardingthetimingofthedrug‘sadministration.
v
DIF: CognitiveLevel:Understanding(Comprehension)
TOP: NursingProcess:Assessment
v v
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v
8. Thenurseisperforminganassessmentofanewlyadmittedpatient.Whichisanexampleof
subjectivedata?
v
a. Weight155pounds
b. Pulse72beats/minute
c. Thepatientreportsthatheusestheherbalproductginkgo
d. Thepatient‘scompletebloodcountresults
ANS: Cv
Subjectivedataincludeinformationsharedthroughthespokenwordbyanyreliablesource,suchas
thepatient.Objectivedatamaybedefinedasanyinformationgatheredthroughthesensesorthat
v
vwhichisseen,heard,felt,orsmelled.Apatient‘spulse,weight,andlaboratorytestsareallexamples
ofobjectivedata.
v
DIF: CognitiveLevel:Understanding(Comprehension)
TOP: NursingProcess:Assessment
v v
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v
MULTIPLERESPONSE
1. Whengivingmedications,thenursewillfollowtherightsofmedicationadministration.Therights
include the right documentation, the right reason, the right response, and the patient‘s right to
v v v v v v v v v v v v v v v
refuse.Whichoftheseareadditionalrights?(Selectallthatapply.)
v
a. Rightdrug
b. Rightroute
c. Rightdose
d. Rightdiagnosis
e. Righttime
f. Rightpatient
ANS: A,B,C,E,F
v
Additionalrightsofmedicationadministrationmustalwaysincludetherightdrug,rightdose,right
time,rightroute,andrightpatient.Therightdiagnosisisincorrect.
v
DIF: CognitiveLevel:Remembering (Knowledge) b
TOP: NursingProcess:Implementation
v v
PRIMEXAM.COM
, MSC: NCLEX:SafeandEffectiveCareEnvironment:SafetyandInfectionControl
v
OTHER
1. Placethephasesofthenursingprocessinthecorrectorder,with1asthefirstphaseand5asthelast
phase.
v
a. Planning
b. Evaluation
c. Assessment
d. Implementation
e. Humanneedsstatement
ANS:
C,E,A,D,B
Thenursingprocessisanongoingprocessthatbeginswithassessingandcontinueswithhuman
needsstatement,planning,implementing,andevaluating.
v
DIF: CognitiveLevel:Applying(Application) TOP: NursingProcess:General
v
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v v
PRIMEXAM.COM
Lilley:PharmacologyandtheNursingProcess,10thEdition
v
MULTIPLECHOICE
1. Thenurseisdevelopingahumanneedsstatementforapatientwhohasanewdiagnosisofheart
v failure.Identificationofhumanneedsstatementsoccurwithwhichoftheseactivities?
a. Collectionofpatientdata
b. Administeringinterventions
c. Decidingonpatientoutcomes
d. Documentingthepatient‘sbehavior
ANS: A v
Identificationofhumanneedsoccurswiththecollectionofpatientdata.
DIF: CognitiveLevel:Understanding(Comprehension)
TOP: NursingProcess:HumanNeedsStatement
v v
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v
2. Thepatientistoreceiveoralguaifenesintwiceaday.Today,thenursewasbusyandgavethe
medication2hoursafterthescheduleddosewasdue.Whattypeofproblemdoesthisrepresent?
v
a.―Righttime‖
b.―Rightdose‖
c.―Rightroute‖
d.―Rightmedication‖
ANS: A v
―Righttime‖iscorrectbecausethemedicationwasgivenmorethan30minutesafterthescheduled
dosewasdue.―Dose‖isincorrectbecausethedoseisnotrelatedtothetimethemedication
v
administrationisscheduled.―Route‖isincorrectbecausetherouteisnotaffected.
v
―Medication‖isincorrectbecausethemedicationorderedwillnotchange.
DIF: CognitiveLevel:Applying(Application)
TOP: NursingProcess:Implementation
v v
MSC: NCLEX:SafeandEffectiveCareEnvironment:SafetyandInfectionControl
v
3. Thenursehasbeenmonitoringthepatient‘sprogressonanewdrugregimensincethefirstdose
vanddocumentingthepatient‘stherapeuticresponsetothemedication.Whichphaseofthe
nursingprocessdotheseactionsillustrate?
v
a. Humanneedsstatement
b. Planning
c. Implementation
d. Evaluation
ANS: D v
Monitoring the patient‘s progress, including the patient‘s response to the medication, is part of the
v v v v v v v v v v v v v v
evaluation phase. Planning, implementation, and human needs statement are not illustrated bythis
v v v v v v v v v v v v
example.
v
DIF: CognitiveLevel:Understanding(Comprehension)
v TOP: NursingProcess:Evaluation
v
PRIMEXAM.COM
, MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v
4. Thenurseisassignedtoapatientwhoisnewlydiagnosedwithtype1diabetesmellitus.
Whichstatementbestillustratesanoutcomecriterionforthispatient?
v
a.Thepatientwillfollowinstructions.
b.Thepatientwillnotexperiencecomplications.
c.Thepatientwilladheretothenewinsulintreatmentregimen.
d.Thepatientwilldemonstratecorrectbloodglucosetestingtechnique.
ANS: D v
―Demonstratingcorrectbloodglucosetestingtechnique‖isaspecificandmeasurableoutcome
criterion.―Followinginstructions‖and―notexperiencingcomplications‖arenotspecificcriteria.
v
―Adheringtonewregimen‖wouldbedifficulttomeasure.
DIF: CognitiveLevel:Applying(Application) TOP: NursingProcess:Planning
v
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v v
5. Whichactivitybestreflectstheimplementationphaseofthenursingprocessforthepatientwhois
newlydiagnosedwithhypertension?
v
a. Providingeducationonkeepingajournalofbloodpressurereadings
b. Settinggoalsandoutcomecriteriawiththepatient‘sinput
c. Recordingadrughistoryregardingover-the-countermedicationsusedathome
d. Formulatinghumanneedsstatementsregardingdeficientknowledgerelatedtothenew
treatmentregimen
v
ANS: A v
Educationisaninterventionthatoccursduringtheimplementationphase.Settinggoalsandoutcomes
reflectstheplanningphase.Recordingadrughistoryreflectstheassessmentphase.Formulatinghuman
v
needsstatementsreflectsanalysisofdataaspartofplanning.
v
DIF: CognitiveLevel:Applying(Application)
TOP: NursingProcess:Implementation
v v
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v
6. Themedicationorderreads,―Giveondansetron4mg,30minutesbeforebeginning
vchemotherapytopreventnausea.‖Thenursenotesthattherouteismissingfromtheorder.What
isthenurse‘sbestaction?
v
a. Givethemedicationintravenouslybecausethepatientmightvomit.
b. Givethemedicationorallybecausethetabletsareavailablein4-mgdoses.
c. Contacttheprescribertoclarifytherouteofthemedicationordered.
d. Holdthemedicationuntiltheprescriberreturnstomakerounds.
ANS: C v
Acompletemedicationorderincludestherouteofadministration.Ifamedicationorderdoesnot
includetheroute,thenursemustasktheprescribertoclarifyit.Theintravenousandoralroutesare
v
notinterchangeable.Holdingthemedicationuntiltheprescriberreturnswouldmeanthatthe
v
vpatientwouldnotreceiveaneededmedication.
DIF: CognitiveLevel:Applying(Application)
TOP: NursingProcess:Implementation
v v
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v
PRIMEXAM.COM
, 7. Whenthenurseconsidersthetimingofadrugdose,whichfactorisappropriatetoconsiderwhen
decidingwhentogiveadrug?
v
a. Thepatient‘sabilitytoswallow
b. Thepatient‘sheight
c. Thepatient‘slastmeal
d. Thepatient‘sallergies
ANS: Cv
Thenursemust consider specific pharmacokinetic/pharmacodynamic drugpropertiesthat may be
v v v v v v
affected by the timingofthelastmeal. Thepatient‘sability to swallow, height, andallergies arenot
v v v v v v v v v v
factorstoconsiderregardingthetimingofthedrug‘sadministration.
v
DIF: CognitiveLevel:Understanding(Comprehension)
TOP: NursingProcess:Assessment
v v
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v
8. Thenurseisperforminganassessmentofanewlyadmittedpatient.Whichisanexampleof
subjectivedata?
v
a. Weight155pounds
b. Pulse72beats/minute
c. Thepatientreportsthatheusestheherbalproductginkgo
d. Thepatient‘scompletebloodcountresults
ANS: Cv
Subjectivedataincludeinformationsharedthroughthespokenwordbyanyreliablesource,suchas
thepatient.Objectivedatamaybedefinedasanyinformationgatheredthroughthesensesorthat
v
vwhichisseen,heard,felt,orsmelled.Apatient‘spulse,weight,andlaboratorytestsareallexamples
ofobjectivedata.
v
DIF: CognitiveLevel:Understanding(Comprehension)
TOP: NursingProcess:Assessment
v v
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v
MULTIPLERESPONSE
1. Whengivingmedications,thenursewillfollowtherightsofmedicationadministration.Therights
include the right documentation, the right reason, the right response, and the patient‘s right to
v v v v v v v v v v v v v v v
refuse.Whichoftheseareadditionalrights?(Selectallthatapply.)
v
a. Rightdrug
b. Rightroute
c. Rightdose
d. Rightdiagnosis
e. Righttime
f. Rightpatient
ANS: A,B,C,E,F
v
Additionalrightsofmedicationadministrationmustalwaysincludetherightdrug,rightdose,right
time,rightroute,andrightpatient.Therightdiagnosisisincorrect.
v
DIF: CognitiveLevel:Remembering (Knowledge) b
TOP: NursingProcess:Implementation
v v
PRIMEXAM.COM
, MSC: NCLEX:SafeandEffectiveCareEnvironment:SafetyandInfectionControl
v
OTHER
1. Placethephasesofthenursingprocessinthecorrectorder,with1asthefirstphaseand5asthelast
phase.
v
a. Planning
b. Evaluation
c. Assessment
d. Implementation
e. Humanneedsstatement
ANS:
C,E,A,D,B
Thenursingprocessisanongoingprocessthatbeginswithassessingandcontinueswithhuman
needsstatement,planning,implementing,andevaluating.
v
DIF: CognitiveLevel:Applying(Application) TOP: NursingProcess:General
v
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v v
PRIMEXAM.COM
