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@ diagnos
is@ 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@(Comprehensio
n)@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@ga
ve@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@ sc
heduled@dose@ was@due.@―Dose‖@is@incorrect@because@the@dose@is@ not@related@ to@the@time@the@ m
edication@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@pa
rt@of@ the@evaluation@phase.@ Planning,@implementation,@and@human@needs@statement@are@not@i
llustrated@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@ mel
litus.@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@no
t@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@pa
tient@ 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@ o
utcomes@reflects@the@planning@phase.@Recording@a@drug@history@reflects@the@assessment@phase.@F
ormulating@ 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@c
hemotherapy@to@prevent@ nausea.‖@The@nurse@notes@that@the@route@is@missing@ from@the@or
der.@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@d
oes@ 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@return
s@ 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
, 7. When@the@nurse@considers@the@timing@of@a@drug@dose,@which@ factor@is@appropriate@to@con
sider@ when@deciding@ when@to@give@a@drug?
a. The@patient‘s@ability@to@swallow
b. The@patient‘s@height
c. The@patient‘s@last@ meal
d. The@patient‘s@allergies
ANS:@ C
The@nurse@must@consider@specific@pharmacokinetic/pharmacodynamic@drug@properties@that@
may@ be@affected@by@the@timing@ of@the@last@ meal.@The@patient‘s@ability@to@ swallow,@ height,@a
nd@allergies@are@ not@ factors@to@ consider@regarding@the@timing@of@the@drug‘s@administration.
DIF:
Cognitive@Level:@Understanding@(Comprehensio
n)@TOP:@ Nursing@Process:@Assessment
MSC:@ NCLEX:@Safe@and@Effective@Care@Environment:@Management@of@Care
8. The@nurse@is@performing@an@assessment@of@a@newly@admitted@patient.@Which@is@an@examp
le@of@ subjective@data?
a. Weight@155@pounds
b. Pulse@72@beats/minute
c. The@patient@reports@that@ he@uses@the@herbal@ product@ ginkgo
d. The@patient‘s@complete@ blood@count@results
ANS:@ C
Subjective@data@include@information@ shared@through@the@ spoken@ word@ by@any@reliable@ sourc
e,@ such@as@the@ patient.@Objective@ data@may@be@defined@as@any@information@gathered@throug
h@the@ senses@or@that@which@is@seen,@heard,@felt,@or@smelled.@A@patient‘s@pulse,@weight,@and@l
aboratory@tests@are@all@ examples@of@ objective@ data.
DIF:
Cognitive@Level:@Understanding@(Comprehensio
n)@TOP:@ Nursing@Process:@Assessment
MSC:@ NCLEX:@Safe@and@Effective@Care@Environment:@Management@of@Care
MULTIPLE@RESPONSE
1. When@giving@medications,@the@nurse@will@follow@the@rights@of@ medication@administration.@
The@rights@include@the@right@documentation,@the@right@reason,@the@right@response,@and@the@
patient‘s@right@ to@refuse.@Which@ of@these@are@additional@rights?@(Select@all@that@apply.)
a. Right@ drug
b. Right@route
c. Right@ dose
d. Right@diagnosis
e. Right@ time
f. Right@patient
ANS:@ A,@B,@C,@E,@F
Additional@rights@of@medication@administration@must@always@include@the@right@drug,@right@d
ose,@right@ time,@right@route,@and@right@patient.@The@right@diagnosis@is@incorrect.
DIF:
Cognitive@Level:@Remembering@(Knowledg
e)@TOP:@ Nursing@Process:@Implementation
, 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@an
d@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@ wit
h@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
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@ diagnos
is@ 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@(Comprehensio
n)@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@ga
ve@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@ sc
heduled@dose@ was@due.@―Dose‖@is@incorrect@because@the@dose@is@ not@related@ to@the@time@the@ m
edication@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@pa
rt@of@ the@evaluation@phase.@ Planning,@implementation,@and@human@needs@statement@are@not@i
llustrated@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@ mel
litus.@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@no
t@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@pa
tient@ 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@ o
utcomes@reflects@the@planning@phase.@Recording@a@drug@history@reflects@the@assessment@phase.@F
ormulating@ 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@c
hemotherapy@to@prevent@ nausea.‖@The@nurse@notes@that@the@route@is@missing@ from@the@or
der.@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@d
oes@ 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@return
s@ 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
, 7. When@the@nurse@considers@the@timing@of@a@drug@dose,@which@ factor@is@appropriate@to@con
sider@ when@deciding@ when@to@give@a@drug?
a. The@patient‘s@ability@to@swallow
b. The@patient‘s@height
c. The@patient‘s@last@ meal
d. The@patient‘s@allergies
ANS:@ C
The@nurse@must@consider@specific@pharmacokinetic/pharmacodynamic@drug@properties@that@
may@ be@affected@by@the@timing@ of@the@last@ meal.@The@patient‘s@ability@to@ swallow,@ height,@a
nd@allergies@are@ not@ factors@to@ consider@regarding@the@timing@of@the@drug‘s@administration.
DIF:
Cognitive@Level:@Understanding@(Comprehensio
n)@TOP:@ Nursing@Process:@Assessment
MSC:@ NCLEX:@Safe@and@Effective@Care@Environment:@Management@of@Care
8. The@nurse@is@performing@an@assessment@of@a@newly@admitted@patient.@Which@is@an@examp
le@of@ subjective@data?
a. Weight@155@pounds
b. Pulse@72@beats/minute
c. The@patient@reports@that@ he@uses@the@herbal@ product@ ginkgo
d. The@patient‘s@complete@ blood@count@results
ANS:@ C
Subjective@data@include@information@ shared@through@the@ spoken@ word@ by@any@reliable@ sourc
e,@ such@as@the@ patient.@Objective@ data@may@be@defined@as@any@information@gathered@throug
h@the@ senses@or@that@which@is@seen,@heard,@felt,@or@smelled.@A@patient‘s@pulse,@weight,@and@l
aboratory@tests@are@all@ examples@of@ objective@ data.
DIF:
Cognitive@Level:@Understanding@(Comprehensio
n)@TOP:@ Nursing@Process:@Assessment
MSC:@ NCLEX:@Safe@and@Effective@Care@Environment:@Management@of@Care
MULTIPLE@RESPONSE
1. When@giving@medications,@the@nurse@will@follow@the@rights@of@ medication@administration.@
The@rights@include@the@right@documentation,@the@right@reason,@the@right@response,@and@the@
patient‘s@right@ to@refuse.@Which@ of@these@are@additional@rights?@(Select@all@that@apply.)
a. Right@ drug
b. Right@route
c. Right@ dose
d. Right@diagnosis
e. Right@ time
f. Right@patient
ANS:@ A,@B,@C,@E,@F
Additional@rights@of@medication@administration@must@always@include@the@right@drug,@right@d
ose,@right@ time,@right@route,@and@right@patient.@The@right@diagnosis@is@incorrect.
DIF:
Cognitive@Level:@Remembering@(Knowledg
e)@TOP:@ Nursing@Process:@Implementation
, 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@an
d@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@ wit
h@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
