Chapter01:TheNursingProcessandDrugTherapy
Lilley:PharmacologyandtheNursingProcess,10thEditio
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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
v medication2hoursafterthescheduleddosewasdue.Whattypeofproblemdoesthisrepresent?
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
anddocumentingthepatient‘stherapeuticresponsetothemedication.Whichphaseofthe
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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
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evaluation phase. Planning, implementation, and human needs statement are not illustrated bythis
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example.
v
DIF: CognitiveLevel:Understanding(Comprehension)
v TOP: NursingProcess:Evaluation
v
PRIMEXAM.COM
, MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v
4. Thenurseisassignedtoapatientwhoisnewlydiagnosedwithtype1diabetesmellitus.
v Whichstatementbestillustratesanoutcomecriterionforthispatient?
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.Formulatinghuma
v
nneedsstatementsreflectsanalysisofdataaspartofplanning.
v
DIF: CognitiveLevel:Applying(Application)
TOP: NursingProcess:Implementation
v v
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v
6. Themedicationorderreads,―Giveondansetron4mg,30minutesbeforebeginning
chemotherapytopreventnausea.‖Thenursenotesthattherouteismissingfromtheorder.What
v
isthenurse‘sbestaction?
v
a. Givethemedicationintravenouslybecausethepatientmightvomit.
b. Givethemedicationorallybecausethetabletsareavailablein4-mgdoses.
c. Contacttheprescribertoclarifytherouteofthemedicationordered.
d. Holdthemedicationuntiltheprescriberreturnstomakerounds.
ANS: C v
Acompletemedicationorderincludestherouteofadministration.Ifamedicationorderdoesnot
includetheroute,thenursemustasktheprescribertoclarifyit.Theintravenousandoralroutesare
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notinterchangeable.Holdingthemedicationuntiltheprescriberreturnswouldmeanthatthe
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patientwouldnotreceiveaneededmedication.
v
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: C v
Thenursemust consider specific pharmacokinetic/pharmacodynamic drugpropertiesthat may be
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affected by the timingofthelastmeal. Thepatient‘sability to swallow, height, andallergies arenot
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factorstoconsiderregardingthetimingofthedrug‘sadministration.
v
DIF: CognitiveLevel:Understanding(Comprehension)
TOP: NursingProcess:Assessment
v v
MSC: NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
v
8. Thenurseisperforminganassessmentofanewlyadmittedpatient.Whichisanexampleof
v subjectivedata?
a. Weight155pounds
b. Pulse72beats/minute
c. Thepatientreportsthatheusestheherbalproductginkgo
d. Thepatient‘scompletebloodcountresults
ANS: C v
Subjectivedataincludeinformationsharedthroughthespokenwordbyanyreliablesource,suchas
thepatient.Objectivedatamaybedefinedasanyinformationgatheredthroughthesensesorthat
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whichisseen,heard,felt,orsmelled.Apatient‘spulse,weight,andlaboratorytestsareallexamples
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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
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refuse.Whichoftheseareadditionalrights?(Selectallthatapply.)
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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
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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
