,Chapter 01: The Nursing Process and Patient-Centered Care
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McCuistion: Pharmacology: A Patient-Centered Nursing Process Approach, 11th Edition
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MULTIPLE CHOICE v
1. All of the following would be considered subjective data, EXCEPT:
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a. Patient-reported health history v v
b. Patient-reported signs and symptoms of their illness v v v v v v
c. Financial barriers reported by the patient’s caregiver v v v v v v
d. Vital signs obtained from the medical record
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ANS: v D
Subjective data is based on what patients or family members communicate to the
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vnurse. Patient- reported health history, signs and symptoms, and caregiver reported
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vfinancial barriers would be considered subjective data. Vital signs obtained from the
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vmedical record would be considered objective data.
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DIF: Cognitive Level: Understanding (Comprehension) v v v TOP: Nursing v
vProcess: Planning MSC: v v NCLEX: Management v
vof Client Care
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2. The nurse is using data collected to define a set of interventions to achieve the
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v most desirable outcomes. Which of the following steps is the nurse applying?
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a. Recognizing cues (assessment) v v
b. Analyze cues & prioritize hypothesis (analysis) v v v v v
c. Generate solutions (planning) v v
d. Take action (nursing interventions) v v v
ANS: v C
When generating solutions (planning), the nurse identifies expected outcomes
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v and uses the patient’s problem(s) to define a set of interventions to achieve the
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vmost desirable outcomes. Recognizing cues (assessment) involves the gathering of
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vcues (information) from the patient about their health and lifestyle practices, which
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vare important facts that aid the nurse in making clinical care decisions.
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vPrioritizing hypothesis is used to organize and rank the patient problem(s) identified.
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vFinally, taking action involves implementation of nursing interventions to accomplish
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vthe expected outcomes.
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DIF: Cognitive Level: Understanding v v
(Comprehension) TOP: Nursing Process:
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vNursing Intervention v
MSC: NCLEX: Management of Client Care
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3. A 5-year-old child with type 1 diabetes mellitus has had repeated hospitalizations for
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vepisodes of hyperglycemia. The parents tell the nurse that they can’t keep track of
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v everything that has to be done to care for their child. The nurse reviews
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v medications, diet, and symptom management with the parents and draws up a daily
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v checklist for the family to use. These activities are completed in which step of
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v the nursing process?
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a. Recognizing cues (assessment) v v
b. Analyze cues & prioritize hypothesis (analysis) v v v v v
, c. Generate solutions (planning) v v
d. Take action (nursing interventions)
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ANS: v D
Taking action through nursing interventions is where the nurse provides patient health
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vteaching, drug administration, patient care, and other interventions necessary to assist
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v the patient in accomplishing expected outcomes.
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DIF: Cognitive Level: Understanding v v
v(Comprehension) TOP: Nursing Process: v v v
v Nursing Intervention v
MSC: NCLEX: Management of Client Care
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4. The nurse is preparing to administer a medication and reviews the patient’s
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v chart for drug allergies, serum creatinine, and blood urea nitrogen (BUN)
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v levels. The nurse’s actions are reflective of which of the following?
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a. Recognizing cues (assessment) v v
b. Analyze cues & prioritize hypothesis (analysis) v v v v v
c. Take action (nursing interventions)
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d. Generate solutions (planning) v v
ANS: v A
Recognizing cues (assessment) involves gathering subjective and objective information
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vabout the patient and the medication. Laboratory values from the patient’s chart
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vwould be considered collection of objective data.
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DIF: Cognitive Level: Understanding (Comprehension) v v v
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Client Care v v v v v v v v
5. Which of the following would be correctly categorized as objective data?
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a. A list of herbal supplements regularly used provided by the patient.
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b. Lab values associated with the drugs the patient is taking.
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c. The ages and relationship of all household members to the patient.
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d. Usual dietary patterns and food intake.
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ANS: v B
Objective data are measured and detected by another person and would include lab
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vvalues. The other examples are subjective data.
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DIF: Cognitive Level: Understanding (Comprehension) v v v
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Client Care v v v v v v v v
6. The nurse reviews a patient’s database and learns that the patient lives alone,
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v is forgetful, and does not have an established routine. The patient will be sent
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v home with three new medications to be taken at different times of the day. The
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v nurse develops a daily medication chart and enlists a family member to put the
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v patient’s pills in a pill organizer. This is an example of which element of the
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v nursing process? v
a. Recognizing cues (assessment) v v
b. Analyze cues & prioritize hypothesis (analysis) v v v v v
c. Take action (nursing interventions)
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, d. Generate solutions (planning) v v
ANS: v C
Taking action (nursing interventions) involves education and patient care in order to
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assist the patient to accomplish the goals of treatment.
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DIF: Cognitive Level: Applying v v
(Application) TOP: Nursing
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Process:
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Nursing Intervention MSC: NCLEX: v v
Management of Client Care v v v
7. A patient who is hospitalized for chronic obstructive pulmonary disease (COPD)
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wants to go home. The nurse and the patient discuss the patient’s situation and
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decide that the patient may go home when able to perform self-care without dyspnea
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and hypoxia. This is an example of which phase of the nursing process?
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a. Recognizing cues (assessment) v v
b. Analyze cues & prioritize hypothesis (analysis) v v v v v
c. Take action (nursing interventions) v v v
d. Generate solutions (planning) v v
ANS: v D
Generating solutions (planning) involves defining a set of interventions to
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achieve the most desirable outcomes, which, for this patient, means being able
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to perform self-care activities without dyspnea and hypoxia.
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DIF: Cognitive Level: Understanding (Comprehension)
v v v v TOP: v Nursing v Process:
Planning MSC: NCLEX: Management of Client Care
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8. A patient will be sent home with a metered-dose inhaler, and the nurse is
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providing teaching. Which is a correctly written expected outcome for this
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process?
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a. The nurse will demonstrate the correct use of a metered-dose inhaler to the patient.
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b. The nurse will teach the patient how to administer medication
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with a metered-dose inhaler.
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c. The patient will know how to self-administer the medication using
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the metered- dose inhaler.
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d. The patient will independently administer the medication using the
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metered- dose inhaler at the end of the session.
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ANS: v D
Expected outcomes must be patient-centered and clearly state the outcome with a
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reasonable deadline and should identify components for evaluation.
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DIF: Cognitive Level: Applying (Application)
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Planning MSC: NCLEX: Management of Client Care
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9. The nurse is generating solutions (planning) for a patient who has chronic lung
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disease and hypoxia. The patient has been admitted for increased oxygen needs
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above a baseline of 2 L/min. The nurse generates an expected outcomes stating,
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“The patient will have oxygen saturations of
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>95% on room air at the time of discharge from the hospital.” What is wrong with this
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vgoal?
a. It cannot be evaluated.
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