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Pathophysiology (NSG 211)

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Chapter 01: The Nursing Process and Drug Therapy

Lilley: Pharmacology and the Nursing Process, 10th Edition

MULTIPLE CHOICE

1. The nurse is developing a human needs statement for a patient who has a new diagnosis of

heart failure. Identification of human needs statements occur with which of these activities?

a. Collection of patient data

b. Administering interventions

c. Deciding on patient outcomes

d. Documenting the patient’s behavior

ANS: A

Identification of human needs occurs with the collection of patient data.

DIF: Cognitive Level: Understanding (Comprehension)

TOP: Nursing Process: Human Needs Statement

MSC: NCLEX: Safe and Effective Care Environment: Management of Care

2. The patient is to receive oral guaifenesin twice a day. Today, the nurse was busy and gave the

medication 2 hours after the scheduled dose was due. What type of problem does this

represent?

a. “Right time”

b. “Right dose”

c. “Right route”

d. “Right medication”

ANS: A

“Right time” is correct because the medication was given more than 30 minutes after the

scheduled dose was due. “Dose” is incorrect because the dose is not related to the time the

medication administration is scheduled. “Route” is incorrect because the route is not affected.

“Medication” is incorrect because the medication ordered will not change.

DIF: Cognitive Level: Applying (Application)

TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control

3. The nurse has been monitoring the patient’s progress on a new drug regimen since the first

dose and documenting the patient’s therapeutic response to the medication. Which phase of

the nursing process do these actions illustrate?

a. Human needs statement

b. Planning

c. Implementation

d. Evaluation

ANS: D

Monitoring the patient’s progress, including the patient’s response to the medication, is part of

the evaluation phase. Planning, implementation, and human needs statement are not illustrated

by this example.

DIF: Cognitive Level: Understanding (Comprehension) TOP: Nursing Process: Evaluation

MSC: NCLEX: Safe and Effective Care Environment: Management of Care

4. The nurse is assigned to a patient who is newly diagnosed with type 1 diabetes mellitus.

Which statement best illustrates an outcome criterion for this patient?

a. The patient will follow instructions.

b. The patient will not experience complications.

c. The patient will adhere to the new insulin treatment regimen.

d. The patient will demonstrate correct blood glucose testing technique.

ANS: D

“Demonstrating correct blood glucose testing technique” is a specific and measurable

outcome criterion. “Following instructions” and “not experiencing complications” are not

specific criteria. “Adhering to new regimen” would be difficult to measure.

DIF: Cognitive Level: Applying (Application) TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment: Management of Care

5. Which activity best reflects the implementation phase of the nursing process for the patient

who is newly diagnosed with hypertension?

a. Providing education on keeping a journal of blood pressure readings

b. Setting goals and outcome criteria with the patient’s input

c. Recording a drug history regarding over-the-counter medications used at home

d. Formulating human needs statements regarding deficient knowledge related to the

new treatment regimen

ANS: A

Education is an intervention that occurs during the implementation phase. Setting goals and

outcomes reflects the planning phase. Recording a drug history reflects the assessment phase.

Formulating human needs statements reflects analysis of data as part of planning.

DIF: Cognitive Level: Applying (Application)

TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment: Management of Care

6. The medication order reads, “Give ondansetron 4 mg, 30 minutes before beginning

chemotherapy to prevent nausea.” The nurse notes that the route is missing from the order.

What is the nurse’s best action?

a. Give the medication intravenously because the patient might vomit.

b. Give the medication orally because the tablets are available in 4-mg doses.

c. Contact the prescriber to clarify the route of the medication ordered.

d. Hold the medication until the prescriber returns to make rounds.

ANS: C

A complete medication order includes the route of administration. If a medication order does

not include the route, the nurse must ask the prescriber to clarify it. The intravenous and oral

routes are not interchangeable. Holding the medication until the prescriber returns would

mean that the patient would not receive a needed medication.

DIF: Cognitive Level: Applying (Application)

TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment: Management of Care

MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control

OTHER

1. Place the phases of the nursing process in the correct order, with 1 as the first phase and 5 as

the last phase.

a. Planning

b. Evaluation

c. Assessment

d. Implementation

e. Human needs statement

ANS:

C, E, A, D, B

The nursing process is an ongoing process that begins with assessing and continues with

human needs statement, planning, implementing, and evaluating.

DIF: Cognitive Level: Applying (Application) TOP: Nursing Process: General

MSC: NCLEX: Safe and Effective Care Environment: Management of Care

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01 - nona

Course: Pathophysiology (NSG 211)

33 Documents
Students shared 33 documents in this course

University: Marian University

Was this document helpful?
Chapter 01: The Nursing Process and Drug Therapy
Lilley: Pharmacology and the Nursing Process, 10th Edition
MULTIPLE CHOICE
1. The nurse is developing a human needs statement for a patient who has a new diagnosis of
heart failure. Identification of human needs statements occur with which of these activities?
a.
Collection of patient data
b.
Administering interventions
c.
Deciding on patient outcomes
d.
Documenting the patient’s behavior
ANS: A
Identification of human needs occurs with the collection of patient data.
DIF: Cognitive Level: Understanding (Comprehension)
TOP: Nursing Process: Human Needs Statement
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
2. The patient is to receive oral guaifenesin twice a day. Today, the nurse was busy and gave the
medication 2 hours after the scheduled dose was due. What type of problem does this
represent?
a.
“Right time”
b.
“Right dose”
c.
“Right route”
d.
“Right medication”
ANS: A
“Right time” is correct because the medication was given more than 30 minutes after the
scheduled dose was due. “Dose” is incorrect because the dose is not related to the time the
medication administration is scheduled. “Route” is incorrect because the route is not affected.
“Medication” is incorrect because the medication ordered will not change.
DIF: Cognitive Level: Applying (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
3. The nurse has been monitoring the patient’s progress on a new drug regimen since the first
dose and documenting the patient’s therapeutic response to the medication. Which phase of
the nursing process do these actions illustrate?
a.
Human needs statement
b.
Planning
c.
Implementation
d.
Evaluation
ANS: D
Monitoring the patient’s progress, including the patient’s response to the medication, is part of
the evaluation phase. Planning, implementation, and human needs statement are not illustrated
by this example.
DIF: Cognitive Level: Understanding (Comprehension) TOP: Nursing Process: Evaluation