EDITION 58 CHAPTERS LINDA LANE LILLEY, SHELLY
RAINFORTH COLLINS, JULIE S. SNYDER QUESTIONS AND
ANSWERS LATEST UPDATE 2023/2024 ALL ANSWERS 100%
CORRECT
Chapter 01: The Nursing Process and Drug Therapy
MULTIPLE CHOICE
1. During an intravenous (IV) infusion of amphotericin B, a patient develops tingling
and numbnessin his toes and fingers. What will the nurse do first?
a. Discontinue the infusion immediately.
b. Reduce the infusion rate gradually until the adverse effects
subside.
c. Administer the medication by rapid IV infusion to reduce
these effects.
d. Nothing; these are expected side effects of this medication.
ANS: A
Once the intravenous infusion of amphotericin B has begun, vital signs must be
monitored frequently to assess for adverse reactions such as cardiac dysrhythmias,
visual disturbances, paresthesias (numbness or tingling of the hands or feet),
respiratory difficulty, pain, fever, chills,and nausea. If these adverse effects or a
severe reaction occur, the infusion must be discontinued(while the patient is
closely monitored) and the prescriber contacted. The other options are incorrect.
?
,DIF: COGNITIVE LEVEL: Applying
(Application)TOP: NURSING
PROCESS: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
The nurse is writing a nursing diagnosis for a plan of care for a patient who
has been newlydiagnosed with type 2 diabetes. Which statement reflects the
correct format for a nursing diagnosis?
a. Anxiety
b. Anxiety related to new drug therapy
c. Anxiety related to anxious feelings about drug therapy, as evidenced by
statements
such as “I’m upset about having to test my blood sugars.”
d. Anxiety related to new drug therapy, as evidenced by statements such as
“I’m
upset about having to test my blood sugars.”
ANS: D
Formulation of nursing diagnoses is usually a three-step process. “Anxiety” is
missing the
“related to” and “as evidenced by” portions of defining characteristics. “Anxiety
related to new drug therapy” is missing the “as evidenced by” portion of defining
characteristics. The statementbeginning “Anxiety related to anxious feelings” is
incorrect because the “related to” section is simply a restatement of the problem
“anxiety,” not a separate factor related to the response.
DIF: COGNITIVE LEVEL: Understanding
?
, (Comprehension)TOP: NURSING PROCESS:
Nursing Diagnosis
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
2. Thexpatientxisxtoxreceivexoralxguaifenesinx(Mucinex)xtwicexaxday.xToday,xthexnur
sexwasxbusyxandgavexthexmedicationx2xhoursxafterxthexscheduledxdosexwasxdue.x
Whatxtypexofxproblemxdoesxthisxrepresent?
a. “Rightxtime”
b. “Rightxdose”
c. “Rightxroute”
d. “Right
medication”
ANS:x A
“Rightxtime”xisxcorrectxbecausexthexmedicationxwasxgivenxmorexthanx30x
minutesxafterxthexscheduledxdosexwasxdue.x“Dose”xisxincorrectxbecausexth
exdosexisxnotxrelatedxtoxthextimexthe
medicationxadministrationxisxscheduled.x“Route”xisxincorrectxbecausexthexrout
exisxnotxaffected.“Medication”xisxincorrectxbecausexthexmedicationxorderedxwil
lxnotxchange.
DIF:x COGNITIVExLEVEL:xApplying
(Application)TOP:x NURSINGxPROCESS
:xImplementation
MSC:x NCLEX:xSafexandxEffectivexCarexEnvironment:xSafetyxandxInfectionxControl
3. Thexnursexhasxbeenxmonitoringxthexpatient’sxprogressxonxaxnewxdrugxregime
nxsincexthexfirstxdoseandxdocumentingxthexpatient’sxtherapeuticxresponsextoxt
he
?
, medication.xWhichxphasexofxthexnursingxprocessedxthesexactionsxillustrate?
a. Nursingx
diagnosis
b. Planning
c. Implementatio
n
x
d. Evaluation
ANS:x D
Monitoringxthexpatient’sxprogress,xincludingxthexpatient’sxresponsextoxthexmedicat
ion,xisxpartxofxthexevaluationxphase.xPlanning,ximplementation,xandxnursingxdiagno
sisxarexnotxillustratedxbyxthisexample.
DIF:xCOGNITIVExLEVEL:xUnderstandingx(Comprehensi
on)TOP:x NURSINGxPROCESS:
Evaluation
MSC:x NCLEX:xSafexandxEffectivexCarexEnvironment:xManagementxofxCare
4. Thexnursexisxassignedxtoxaxpatientxwhoxisxnewlyxdiagnosedxwithxtypex1xdiabet
esxmellitus.xWhichstatementxbestxillustratesxanxoutcomexcriterionxforxthisxpatie
nt?
a. Thexpatientxwillxfollowxinstructions.
b. Thexpatientxwillxnotxexperiencexcomplications.
c. Thexpatientxwillxadherextoxthexnewxinsulinxtreatmentxregimen.
d. Thexpatientxwillxdemonstratexcorrectxbloodxglucosextestin
gxtechnique.
ANS:x D
?