CHAPTER 1:
M
cCuistion:Pharm
acology:APatient-CenteredNursingProcessApproach,10thEdition
TheNursingProcessandPatient-CenteredCare
• The nursing process is a five-step decision-making approach that includes all of the
followingsteps, EXCEPT:
• Assessment
• Patient problem
• Planning
• Right Drug
ANSWERWER:
D
The nursing process is a five-step decision-making approach that includes: 1)
assessment, 2) patient problem, 3) planning, 4) implementation, and 5) evaluation.
“Right drug” is one of the“Six Rights” of medication administration.
DIF: Cognitive Level: Understanding (Comprehension) TOP: Nursing Process:
PlanningMSC: NCLEX: Management of Care
• The nurse is using data collected to set goals or expected outcomes and interventions that
address the patient’s problems. Which step of the nursing process is the nurse applying?
• Assessment
• Patient problem
• Planning
• Evaluation
ANSWERWER: C
During the planning phase, the nurse uses the data collected to set goals or expected
outcomesand interventions which address the patient’s problems. The data was
collected during the “Assessment” and “Patient problem” steps. During the
“Evaluation” phase the nurse would determine whether the goals and objectives set
during the planning phase were met.
DIF: Cognitive Level: Understanding
(Comprehension)TOP: Nursing Process: Nursing
Intervention
MSC: NCLEX: Management of Care
• A 5-year-old child with type 1 diabetes mellitus has had repeated hospitalizations for
episodesof hyperglycemia. The parents tell the nurse that they can’t keep track of
everything that has to be done to care for their child. The nurse reviews medications,
diet, and symptom management with the parents and draws up a daily checklist for the
family to use. These activities are completed in which step of the nursing process?
• Assessment
• Planning
, • Implementation
• Evaluation
ANSWERWER: C
The implementation phase is the part of the nursing process in which the nurse
provides education, drug administration, patient care, and other interventions
necessary to assist thepatient in accomplishing established medication goals.
DIF: Cognitive Level: Understanding
(Comprehension)TOP: Nursing Process: Nursing
Intervention
MSC: NCLEX: Management of Care
• The nurse is preparing to administer a medication and reviews the patient’s chart
for drug allergies, serum creatinine, and blood urea nitrogen (BUN) levels. The
nurse’s actions arereflective of which phase of the nursing process?
• Assessment
• Evaluation
• Implementation
• Planning
ANSWERWER: A
Assessment involves gathering information about the patient and the drug,
including anyprevious use of the drug.
DIF: Cognitive Level: Understanding (Comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care
• Which assessment is categorized as objective data?
• A list of herbal supplements regularly used
• Lab values associated with the drugs the patient is taking
• The ages and relationship to the patient of all household members
• Usual dietary patterns and fNood intake
ANSWERWER: B
Objective data are measured and detected by another person and would include lab
values. The other examples are subjective data.
DIF: Cognitive Level: Understanding (Comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care
• The nurse reviews a patient’s database and learns that the patient lives alone, is
forgetful, anddoes not have an established routine. The patient will be sent home with
three new medications to be taken at different times of the day. The nurse develops a
daily medication chart and enlists a family member to put the patient’s pills in a pill
organizer. This is an example of which phase of the nursing process?
, • Assessment
• Evaluation
• Implementation
• Planning
ANSWERWER: C
The implementation phase involves education and patient care in order to assist the
patient to accomplish the goals of treatment.
DIF: Cognitive Level: Applying
(Application)TOP: Nursing Process:
Nursing Intervention
MSC: NCLEX: Management of Care
• A patient who is hospitalized for chronic obstructive pulmonary disease (COPD)
wants to go home. The nurse and the patient discuss the patient’s situation and decide
that the patient maygo home when able to perform self-care without dyspnea and
hypoxia. This is an example of which phase of the nursing process?
• Assessment
• Evaluation
• Implementation
• Planning
ANSWERWER: D
Planning involves goal setting, which, for this patient, meANSWERWER being able
to perform self-careactivities without dyspnea and hypoxia.
DIF: Cognitive Level: Understanding (Comprehension) TOP: Nursing Process:
PlanningMSC: NCLEX: Management of Care
• A patient will be sent home with a metered-dose inhaler, and the nurse is providing
teaching. Which is a correctly written goal for this process?
• The nurse will demonstrate the correct use of a metered-dose inhaler to the patient.
• The nurse will teach the patient how to administer medication with a
metered-doseinhaler.
• The patient will know how to self-administer the medication
using the metered-dose inhaler.
The patient will independently administer the medication using the
•
metered-doseinhaler at the end of the ses
Nsion.
ANSWERWER: D
Goals must be patient-centered and clearly state the outcome with a reasonable
deadline andshould identify components for evaluation.
DIF: Cognitive Level: Applying (Application) TOP: Nursing Process:
PlanningMSC: NCLEX: Management of Care
, • The nurse is developing a plan of care for a patient who has chronic lung disease and
hypoxia. The patient has been admitted for increased oxygen needs above a baseline of
2 L/min. The nurse develops a goal stating, “The patient will have oxygen saturations
of >95% on room air at the time of discharge from the hospital.” What is wrong with
this goal?
• It cannot be evaluated.
• It is not measurable.
• It is not patient-centered.
• It is not realistic.
ANSWERWER: D
This goal is not realistic because the patient is not usually on room air and should
not beexpected to attain that goal by discharge from this hospitalization.
DIF: Cognitive Level: Applying (Application) TOP: Nursing Process:
PlanningMSC: NCLEX: Management of Care
• The nurse is developing a teaching plan for an elderly patient who will begin
taking an antihypertensive drug that causes dizziness and orthostatic
hypotension. Which patient problem documented by the nurse is appropriate for
this patient?
• Deficient knowledge related to drug side effects
• Ineffective health maintenance related to age
• Readiness for enhanced knowledge related to medication side effects
• Risk for injury related to side effects of the medication
ANSWERWER: D
This patient has an increased risk for injury because of drug side effects, so this is an
appropriate patient problem to direct the type of care and follow-up the patient will
receive.
DIF: Cognitive Level: Applying
(Application)TOP: Nursing Process:
Nursing Diagnosis MSC: NCLEX:
Management of Care
• An older patient must learn to administer a medication using a device that requires
manual dexterity. The patient becomes frustrated and expresses lack of self-
confidence in performing this task. Which action will the nurse perform next?
• Ask the patient to keep trying until the skill is learned.
• Provide written instructions with illustrations showing each step of the skill.
• Schedule multiple sessions and practice each step separately.
• Teach the procedure to family members who can administer the medication
for thepatient.
ANSWERWER: C
M
cCuistion:Pharm
acology:APatient-CenteredNursingProcessApproach,10thEdition
TheNursingProcessandPatient-CenteredCare
• The nursing process is a five-step decision-making approach that includes all of the
followingsteps, EXCEPT:
• Assessment
• Patient problem
• Planning
• Right Drug
ANSWERWER:
D
The nursing process is a five-step decision-making approach that includes: 1)
assessment, 2) patient problem, 3) planning, 4) implementation, and 5) evaluation.
“Right drug” is one of the“Six Rights” of medication administration.
DIF: Cognitive Level: Understanding (Comprehension) TOP: Nursing Process:
PlanningMSC: NCLEX: Management of Care
• The nurse is using data collected to set goals or expected outcomes and interventions that
address the patient’s problems. Which step of the nursing process is the nurse applying?
• Assessment
• Patient problem
• Planning
• Evaluation
ANSWERWER: C
During the planning phase, the nurse uses the data collected to set goals or expected
outcomesand interventions which address the patient’s problems. The data was
collected during the “Assessment” and “Patient problem” steps. During the
“Evaluation” phase the nurse would determine whether the goals and objectives set
during the planning phase were met.
DIF: Cognitive Level: Understanding
(Comprehension)TOP: Nursing Process: Nursing
Intervention
MSC: NCLEX: Management of Care
• A 5-year-old child with type 1 diabetes mellitus has had repeated hospitalizations for
episodesof hyperglycemia. The parents tell the nurse that they can’t keep track of
everything that has to be done to care for their child. The nurse reviews medications,
diet, and symptom management with the parents and draws up a daily checklist for the
family to use. These activities are completed in which step of the nursing process?
• Assessment
• Planning
, • Implementation
• Evaluation
ANSWERWER: C
The implementation phase is the part of the nursing process in which the nurse
provides education, drug administration, patient care, and other interventions
necessary to assist thepatient in accomplishing established medication goals.
DIF: Cognitive Level: Understanding
(Comprehension)TOP: Nursing Process: Nursing
Intervention
MSC: NCLEX: Management of Care
• The nurse is preparing to administer a medication and reviews the patient’s chart
for drug allergies, serum creatinine, and blood urea nitrogen (BUN) levels. The
nurse’s actions arereflective of which phase of the nursing process?
• Assessment
• Evaluation
• Implementation
• Planning
ANSWERWER: A
Assessment involves gathering information about the patient and the drug,
including anyprevious use of the drug.
DIF: Cognitive Level: Understanding (Comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care
• Which assessment is categorized as objective data?
• A list of herbal supplements regularly used
• Lab values associated with the drugs the patient is taking
• The ages and relationship to the patient of all household members
• Usual dietary patterns and fNood intake
ANSWERWER: B
Objective data are measured and detected by another person and would include lab
values. The other examples are subjective data.
DIF: Cognitive Level: Understanding (Comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care
• The nurse reviews a patient’s database and learns that the patient lives alone, is
forgetful, anddoes not have an established routine. The patient will be sent home with
three new medications to be taken at different times of the day. The nurse develops a
daily medication chart and enlists a family member to put the patient’s pills in a pill
organizer. This is an example of which phase of the nursing process?
, • Assessment
• Evaluation
• Implementation
• Planning
ANSWERWER: C
The implementation phase involves education and patient care in order to assist the
patient to accomplish the goals of treatment.
DIF: Cognitive Level: Applying
(Application)TOP: Nursing Process:
Nursing Intervention
MSC: NCLEX: Management of Care
• A patient who is hospitalized for chronic obstructive pulmonary disease (COPD)
wants to go home. The nurse and the patient discuss the patient’s situation and decide
that the patient maygo home when able to perform self-care without dyspnea and
hypoxia. This is an example of which phase of the nursing process?
• Assessment
• Evaluation
• Implementation
• Planning
ANSWERWER: D
Planning involves goal setting, which, for this patient, meANSWERWER being able
to perform self-careactivities without dyspnea and hypoxia.
DIF: Cognitive Level: Understanding (Comprehension) TOP: Nursing Process:
PlanningMSC: NCLEX: Management of Care
• A patient will be sent home with a metered-dose inhaler, and the nurse is providing
teaching. Which is a correctly written goal for this process?
• The nurse will demonstrate the correct use of a metered-dose inhaler to the patient.
• The nurse will teach the patient how to administer medication with a
metered-doseinhaler.
• The patient will know how to self-administer the medication
using the metered-dose inhaler.
The patient will independently administer the medication using the
•
metered-doseinhaler at the end of the ses
Nsion.
ANSWERWER: D
Goals must be patient-centered and clearly state the outcome with a reasonable
deadline andshould identify components for evaluation.
DIF: Cognitive Level: Applying (Application) TOP: Nursing Process:
PlanningMSC: NCLEX: Management of Care
, • The nurse is developing a plan of care for a patient who has chronic lung disease and
hypoxia. The patient has been admitted for increased oxygen needs above a baseline of
2 L/min. The nurse develops a goal stating, “The patient will have oxygen saturations
of >95% on room air at the time of discharge from the hospital.” What is wrong with
this goal?
• It cannot be evaluated.
• It is not measurable.
• It is not patient-centered.
• It is not realistic.
ANSWERWER: D
This goal is not realistic because the patient is not usually on room air and should
not beexpected to attain that goal by discharge from this hospitalization.
DIF: Cognitive Level: Applying (Application) TOP: Nursing Process:
PlanningMSC: NCLEX: Management of Care
• The nurse is developing a teaching plan for an elderly patient who will begin
taking an antihypertensive drug that causes dizziness and orthostatic
hypotension. Which patient problem documented by the nurse is appropriate for
this patient?
• Deficient knowledge related to drug side effects
• Ineffective health maintenance related to age
• Readiness for enhanced knowledge related to medication side effects
• Risk for injury related to side effects of the medication
ANSWERWER: D
This patient has an increased risk for injury because of drug side effects, so this is an
appropriate patient problem to direct the type of care and follow-up the patient will
receive.
DIF: Cognitive Level: Applying
(Application)TOP: Nursing Process:
Nursing Diagnosis MSC: NCLEX:
Management of Care
• An older patient must learn to administer a medication using a device that requires
manual dexterity. The patient becomes frustrated and expresses lack of self-
confidence in performing this task. Which action will the nurse perform next?
• Ask the patient to keep trying until the skill is learned.
• Provide written instructions with illustrations showing each step of the skill.
• Schedule multiple sessions and practice each step separately.
• Teach the procedure to family members who can administer the medication
for thepatient.
ANSWERWER: C
