Chapter 01: The Nursing Process and Drug Therapy
b b b b b b b
Lilley: Pharmacology and the Nursing Process, 10th Edition
b b b b b b b
MULTIPLE CHOICE b
1. The nurse is developing a human needs statement for a patient who has a new diagnosis of
b b b b b b b b b b b b b b b b
heart failure. Identification of human needs statements occur with which of these activities?
b b b b b b b b b b b b b
a. Collection of patient data b b b
b. Administering interventions b
c. Deciding on patient outcomes b b b
d. Documenting the patient‘s behavior b b b
ANS: A b
Identification of human needs occurs with the collection of patient data.
b b b b b b b b b b
DIF: Cognitive Level: Understanding (Comprehension) b b b
TOP: Nursing Process: Human Needs Statement
b b b b b b
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
b b b b b b b b b
2. The patient is to receive oral guaifenesin twice a day. Today, the nurse was busy and gave the
b b b b b b b b b b b b b b b b b
medication 2 hours after the scheduled dose was due. What type of problem does this
b b b b b b b b b b b b b b b
represent?
b
a. ―Right time‖ b
b. ―Right dose‖ b
c. ―Right route‖ b
d. ―Right medication‖ b
ANS: A b
―Right time‖ is correct because the medication was given more than 30 minutes after the
b b b b b b b b b b b b b b
scheduled dose was due. ―Dose‖ is incorrect because the dose is not related to the time the
b b b b b b b b b b b b b b b b b
medication administration is scheduled. ―Route‖ is incorrect because the route is not affected.
b b b b b b b b b b b b b
―Medication‖ is incorrect because the medication ordered will not change.
b b b b b b b b b
DIF: Cognitive Level: Applying (Application) b b b
TOP: Nursing Process: Implementation
b b b b
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
b b b b b b b b b b
3. The nurse has been monitoring the patient‘s progress on a new drug regimen since the first
b b b b b b b b b b b b b b b
dose and documenting the patient‘s therapeutic response to the medication. Which phase of
b b b b b b b b b b b b b
the nursing process do these actions illustrate?
b b b b b b b
a. Human needs statement b b
b. Planning
c. Implementation
d. Evaluation
ANS: D b
Monitoring the patient‘s progress, including the patient‘s response to the medication, is part of
b b b b b b b b b b b b b
the evaluation phase. Planning, implementation, and human needs statement are not illustrated
b b b b b b b b b b b b
by this example.
b b b
DIF: bb b Cognitive Level: Understanding (Comprehension) b b b TOP: Nursing Process: Evaluationb b b
PRIMEXAM.COM
, MSC: NCLEX: Safe and Effective Care Environment: Management of Care
b b b b b b b b b
4. The nurse is assigned to a patient who is newly diagnosed with type 1 diabetes mellitus.
b b b b b b b b b b b b b b b
Which statement best illustrates an outcome criterion for this patient?
b b b b b b b b b b
a. The patient will follow instructions.
b b b b
b. The patient will not experience complications.
b b b b b
c. The patient will adhere to the new insulin treatment regimen.
b b b b b b b b b
d. The patient will demonstrate correct blood glucose testing technique.
b b b b b b b b
ANS: D b
―Demonstrating correct blood glucose testing technique‖ is a specific and measurable outcome b b b b b b b b b b b
criterion. ―Following instructions‖ and ―not experiencing complications‖ are not specific
b b b b b b b b b b
criteria. ―Adhering to new regimen‖ would be difficult to measure.
b b b b b b b b b b
DIF: Cognitive Level: Applying (Application) TOP: Nursing Process: Planning b b b b b b
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
b b b b b b b b b b
5. Which activity best reflects the implementation phase of the nursing process for the patient
b b b b b b b b b b b b b
who is newly diagnosed with hypertension?
b b b b b b
a. Providing education on keeping a journal of blood pressure readings b b b b b b b b b
b. Setting goals and outcome criteria with the patient‘s input
b b b b b b b b
c. Recording a drug history regarding over-the-counter medications used at home b b b b b b b b b
d. Formulating human needs statements regarding deficient knowledge related to the b b b b b b b b b
new treatment regimen
b b b
ANS: A b
Education is an intervention that occurs during the implementation phase. Setting goals and
b b b b b b b b b b b b
outcomes reflects the planning phase. Recording a drug history reflects the assessment phase.
b b b b b b b b b b b b b
Formulating human needs statements reflects analysis of data as part of planning.
b b b b b b b b b b b b
DIF: Cognitive Level: Applying (Application) b b b
TOP: Nursing Process: Implementation
b b b b
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
b b b b b b b b b
6. The medication order reads, ―Give ondansetron 4 mg, 30 minutes before beginning
b b b b b b b b b b b
chemotherapy to prevent nausea.‖ The nurse notes that the route is missing from the order.
b b b b b b b b b b b b b b b
What is the nurse‘s best action?
b b b b b b
a. Give the medication intravenously because the patient might vomit.
b b b b b b b b
b. Give the medication orally because the tablets are available in 4-mg doses.
b b b b b b b b b b b
c. Contact the prescriber to clarify the route of the medication ordered.
b b b b b b b b b b
d. Hold the medication until the prescriber returns to make rounds.
b b b b b b b b b
ANS: C b
A complete medication order includes the route of administration. If a medication order does
b b b b b b b b b b b b b
not include the route, the nurse must ask the prescriber to clarify it. The intravenous and oral
b b b b b b b b b b b b b b b b b
routes are not interchangeable. Holding the medication until the prescriber returns would
b b b b b b b b b b b b
mean that the patient would not receive a needed medication.
b b b b b b b b b b
DIF: Cognitive Level: Applying (Application) b b b
TOP: Nursing Process: Implementation
b b b b
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
b b b b b b b b b
PRIMEXAM.COM
, 7. When the nurse considers the timing of a drug dose, which factor is appropriate to consider
b b b b b b b b b b b b b b b
when deciding when to give a drug?
b b b b b b b
a. The patient‘s ability to swallow b b b b
b. The patient‘s height b b
c. The patient‘s last meal b b b
d. The patient‘s allergies b b
ANS: C b
The nurse must consider specific pharmacokinetic/pharmacodynamic drug properties that may
b b b b b b b b b
be affected by the timing of the last meal. The patient‘s ability to swallow, height, and allergies
b b b b b b b b b b b b b b b b b
are not factors to consider regarding the timing of the drug‘s administration.
b b b b b b b b b b b b
DIF: Cognitive Level: Understanding (Comprehension) b b b
TOP: Nursing Process: Assessment
b b b b
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
b b b b b b b b b
8. The nurse is performing an assessment of a newly admitted patient. Which is an example of
b b b b b b b b b b b b b b b
subjective data?
b b
a. Weight 155 pounds b b
b. Pulse 72 beats/minute b b
c. The patient reports that he uses the herbal product ginkgo
b b b b b b b b b
d. The patient‘s complete blood count results
b b b b b
ANS: C b
Subjective data include information shared through the spoken word by any reliable source,
b b b b b b b b b b b b
such as the patient. Objective data may be defined as any information gathered through the
b b b b b b b b b b b b b b b
senses or that which is seen, heard, felt, or smelled. A patient‘s pulse, weight, and laboratory
b b b b b b b b b b b b b b b b
tests are all examples of objective data.
b b b b b b b
DIF: Cognitive Level: Understanding (Comprehension) b b b
TOP: Nursing Process: Assessment
b b b b
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
b b b b b b b b b
MULTIPLE RESPONSE b
1. When giving medications, the nurse will follow the rights of medication administration. The
b b b b b b b b b b b b
rights include the right documentation, the right reason, the right response, and the patient‘s
b b b b b b b b b b b b b b
right to refuse. Which of these are additional rights? (Select all that apply.)
b b b b b b b b b b b b b
a. Right drug b
b. Right route b
c. Right dose b
d. Right diagnosis b
e. Right time b
f. Right patient b
ANS: A, B, C, E, F b b b b b
Additional rights of medication administration must always include the right drug, right dose,
b b b b b b b b b b b b
right time, right route, and right patient. The right diagnosis is incorrect.
b b b b b b b b b b b b
DIF: Cognitive Level: Remembering (Knowledge) b b b
TOP: Nursing Process: Implementation
b b b b
PRIMEXAM.COM
, MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
b b b b b b b b b b
OTHER
1. Place the phases of the nursing process in the correct order, with 1 as the first phase and 5 asthe
b b b b b b b b b b b b b b b b b b b b
blast phase.
b
a. Planning
b. Evaluation
c. Assessment
d. Implementation
e. Human needs statement b b
ANS:
C, E, A, D, B
b b b b
The nursing process is an ongoing process that begins with assessing and continues with
b b b b b b b b b b b b b
human needs statement, planning, implementing, and evaluating.
b b b b b b b
DIF: Cognitive Level: Applying (Application) bTOP: Nursing Process: General
b b b b b
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
b b b b b b b b b b
PRIMEXAM.COM
