Chapter 1: The Nursing Process & Drug Therapy | Pharmacology & Nursing Process 10th Ed.

Chapterj01:jThejNursingjProcessjandjDrugjTherapy
Lilley:jPharmacologyjandjthejNursingjProcess,j10thjEdition


MULTIPLEjCHOICE

1. Thejnursejisjdevelopingjajhumanjneedsjstatementjforjajpatientjwhojhasjajnewjdiagnosisjofjhea
rtjfailure.jIdentificationjofjhumanjneedsjstatementsjoccurjwithjwhichjofjthesejactivities?
a. Collectionjofjpatientjdata
b. Administeringjinterventions
c. Decidingjonjpatientjoutcomes
d. Documentingjthejpatient‘sjbehavior

ANS:j A
Identificationjofjhumanjneedsjoccursjwithjthejcollectionjofjpatientjdata.

DIF:
CognitivejLevel:jUnderstandingj(Comprehension)j
TOP:j NursingjProcess:jHumanjNeedsjStatement
MSC:j NCLEX:jSafejandjEffectivejCarejEnvironment:jManagementjofjCare

2. Thejpatientjisjtojreceivejoraljguaifenesinjtwicejajday.jToday,jthejnursejwasjbusyjandjgavejthejme
dicationj2jhoursjafterjthejscheduledjdosejwasjdue.jWhatjtypejofjproblemjdoesjthisjrepresent?
a. ―Rightj time‖
b. ―Rightj dose‖
c. ―Rightj route‖
d. ―Rightj medication‖

ANS:j A
―Rightjtime‖jisjcorrectjbecausejthejmedicationjwasjgivenjmorejthanj30jminutesjafterjthejscheduledj
dosejwasjdue.j―Dose‖jisjincorrectjbecausejthejdosejisjnotjrelatedjtojthejtimejthejmedicationjadminist
rationjisjscheduled.j―Route‖jisjincorrectjbecausejthejroutejisjnotjaffected.
―Medication‖jisjincorrectjbecausejthejmedicationjorderedjwilljnotjchange.

DIF:
CognitivejLevel:jApplyingj(Application)j
TOP:j NursingjProcess:jImplementation
MSC:j NCLEX:jSafejandjEffectivejCarejEnvironment:jSafetyjandjInfectionjControl

3. Thejnursejhasjbeenjmonitoringjthejpatient‘sjprogressjonjajnewjdrugjregimenjsincejthejfirstjdos
ejandjdocumentingjthejpatient‘sjtherapeuticjresponsejtojthejmedication.jWhichjphasejofjthejnu
rsingjprocessjdojthesejactionsjillustrate?
a. Humanjneedsjstatement
b. Planning
c. Implementation
d. Evaluation

ANS:j D
Monitoringjthejpatient‘sjprogress,jincludingjthejpatient‘sjresponsejtojthejmedication,jisjpartjofjth
ejevaluationjphase.jPlanning,jimplementation,jandjhumanjneedsjstatementjarejnotjillustratedjbyjt
hisjexample.

DIF:j j CognitivejLevel:jUnderstandingj(Comprehension) TOP:j NursingjProcess:jEvaluation

, MSC:j NCLEX:jSafejandjEffectivejCarejEnvironment:jManagementjofjCare

4. Thejnursejisjassignedjtojajpatientjwhojisjnewlyjdiagnosedjwithjtypej1jdiabetesjmellitus.jW
hichjstatementjbestjillustratesjanjoutcomejcriterionjforjthisjpatient?
a. Thejpatientjwilljfollowjinstructions.
b. Thejpatientjwilljnotjexperiencejcomplications.
c. Thejpatientjwilljadherejtojthejnewjinsulinjtreatmentjregimen.
d. Thejpatientjwilljdemonstratejcorrectjbloodjglucosejtestingjtechnique.

ANS:j D
―Demonstratingjcorrectjbloodjglucosejtestingjtechnique‖jisjajspecificjandjmeasurablejoutco
mejcriterion.j―Followingjinstructions‖jandj―notjexperiencingjcomplications‖jarejnotjspecificjc
riteria.j―Adheringjtojnewjregimen‖jwouldjbejdifficultjtojmeasure.

DIF: CognitivejLevel:jApplyingj(Application)
TOP:j NursingjProcess:jPlanningjMSC:j NCLEX:jSafejandjEffectivejCarejEnvironment:jMana
gementjofjCare

5. Whichjactivityjbestjreflectsjthejimplementationjphasejofjthejnursingjprocessjforjthejpatientjw
hojisjnewlyjdiagnosedjwithjhypertension?
a. Providingjeducationjonjkeepingjajjournaljofjbloodjpressurejreadings
b. Settingjgoalsjandjoutcomejcriteriajwithjthejpatient‘sjinput
c. Recordingjajdrugjhistoryjregardingjover-the-counterjmedicationsjusedjatjhome
d. Formulatingjhumanjneedsjstatementsjregardingjdeficientjknowledgejrelatedjtojthejn
ewjtreatmentjregimen
ANS:j A
Educationjisjanjinterventionjthatjoccursjduringjthejimplementationjphase.jSettingjgoalsjandjoutcome
sjreflectsjthejplanningjphase.jRecordingjajdrugjhistoryjreflectsjthejassessmentjphase.jFormulatingjhu
manjneedsjstatementsjreflectsjanalysisjofjdatajasjpartjofjplanning.

DIF:
CognitivejLevel:jApplyingj(Application)j
TOP:j NursingjProcess:jImplementation
MSC:j NCLEX:jSafejandjEffectivejCarejEnvironment:jManagementjofjCare

6. Thejmedicationjorderjreads,j―Givejondansetronj4jmg,j30jminutesjbeforejbeginningjchemot
herapyjtojpreventjnausea.‖jThejnursejnotesjthatjthejroutejisjmissingjfromjthejorder.jWhatjisjth
ejnurse‘sjbestjaction?
a. Givejthejmedicationjintravenouslyjbecausejthejpatientjmightjvomit.
b. Givejthejmedicationjorallyjbecausejthejtabletsjarejavailablejinj4-mgjdoses.
c. Contactjthejprescriberjtojclarifyjthejroutejofjthejmedicationjordered.
d. Holdjthejmedicationjuntiljthejprescriberjreturnsjtojmakejrounds.

ANS:j C
Ajcompletejmedicationjorderjincludesjthejroutejofjadministration.jIfjajmedicationjorderjdoesjnotji
ncludejthejroute,jthejnursejmustjaskjthejprescriberjtojclarifyjit.jThejintravenousjandjoraljroutesjar
ejnotjinterchangeable.jHoldingjthejmedicationjuntiljthejprescriberjreturnsjwouldjmeanjthatjthejp
atientjwouldjnotjreceivejajneededjmedication.

DIF:
CognitivejLevel:jApplyingj(Application)j
TOP:j NursingjProcess:jImplementation
MSC:j NCLEX:jSafejandjEffectivejCarejEnvironment:jManagementjofjCare

, 7. Whenjthejnursejconsidersjthejtimingjofjajdrugjdose,jwhichjfactorjisjappropriatejtojconsiderjwh
enjdecidingjwhenjtojgivejajdrug?
a. Thejpatient‘sjabilityjtojswallow
b. Thejpatient‘sjheight
c. Thejpatient‘sjlastjmeal
d. Thejpatient‘sjallergies

ANS:j C
Thejnursejmustjconsiderjspecificjpharmacokinetic/pharmacodynamicjdrugjpropertiesjthatjmayjb
ejaffectedjbyjthejtimingjofjthejlastjmeal.jThejpatient‘sjabilityjtojswallow,jheight,jandjallergiesjare
jnotjfactorsjtojconsiderjregardingjthejtimingjofjthejdrug‘sjadministration.


DIF:
CognitivejLevel:jUnderstandingj(Comprehension)j
TOP:j NursingjProcess:jAssessment
MSC:j NCLEX:jSafejandjEffectivejCarejEnvironment:jManagementjofjCare

8. Thejnursejisjperformingjanjassessmentjofjajnewlyjadmittedjpatient.jWhichjisjanjexamplejofjsu
bjectivejdata?
a. Weightj155jpounds
b. Pulsej72jbeats/minute
c. Thejpatientjreportsjthatjhejusesjthejherbaljproductj ginkgo
d. Thejpatient‘sjcompletejbloodjcountjresults

ANS:j C
Subjectivejdatajincludejinformationjsharedjthroughjthejspokenjwordjbyjanyjreliablejsource,jsuch
jasjthejpatient.jObjectivejdatajmayjbejdefinedjasjanyjinformationjgatheredjthroughjthejsensesjorjt
hatjwhichjisjseen,jheard,jfelt,jorjsmelled.jAjpatient‘sjpulse,jweight,jandjlaboratoryjtestsjarejalljexa
mplesjofjobjectivejdata.

DIF:
CognitivejLevel:jUnderstandingj(Comprehension)j
TOP:j NursingjProcess:jAssessment
MSC:j NCLEX:jSafejandjEffectivejCarejEnvironment:jManagementjofjCare


MULTIPLEjRESPONSE

1. Whenjgivingjmedications,jthejnursejwilljfollowjthejrightsjofjmedicationjadministration.jThejri
ghtsjincludejthejrightjdocumentation,jthejrightjreason,jthejrightjresponse,jandjthejpatient‘sjrigh
tjtojrefuse.jWhichjofjthesejarejadditionaljrights?j(Selectjalljthatjapply.)
a. Rightjdrug
b. Rightjroute
c. Rightjdose
d. Rightjdiagnosis
e. Rightjtime
f. Rightjpatient

ANS:j A,jB,jC,jE,jF
Additionaljrightsjofjmedicationjadministrationjmustjalwaysjincludejthejrightjdrug,jrightjdose,jrig
htjtime,jrightjroute,jandjrightjpatient.jThejrightjdiagnosisjisjincorrect.

DIF:
CognitivejLevel:jRememberingj(Knowledge)j
TOP:j NursingjProcess:jImplementation

, MSC:j NCLEX:jSafejandjEffectivejCarejEnvironment:jSafetyjandjInfectionjControl


OTHER

1. Placejthejphasesjofjthejnursingjprocessjinjthejcorrectjorder,jwithj1jasjthejfirstjphasejandj5jasjthejl
astjphase.

a. Planning
b. Evaluation
c. Assessment
d. Implementation
e. Humanjneedsjstatement

ANS:
C,jE,jA,jD,jB

Thejnursingjprocessjisjanjongoingjprocessjthatjbeginsjwithjassessingjandjcontinuesjwithjhuma
njneedsjstatement,jplanning,jimplementing,jandjevaluating.

DIF: CognitivejLevel:jApplyingj(Application)
TOP:j NursingjProcess:jGeneraljMSC:j NCLEX:jSafejandjEffectivejCarejEnvironment:jMana
gementjofjCare