Test Bank Pharmacology and the Nursing Process 9th Edition
Test Bank - 9780323529495 All Chapters | All Chapters with
Answers and Rationals
A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the
client's vital signs, the nurse is implementing which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation - ANSWER: A. Assessment
Rationale: The first step in the nursing process is assessment, the process of collecting data. All
subsequent phases of the nursing process (options 2, 3, and 4) rely on accurate and complete data.
The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of
the following should the nurse record as objective data?
A. The client reports abdominal pain
B. The client's urine output was 450 mL
C. The client states, "I didn't see any stones in my urine."
D. The client states, "I feel like I have passed a stone." - ANSWER: B. The client's urine output was 450
mL.
Rationale: Objective data is measurable data that can be seen, heard, or verified by the nurse. The
objective data is the measurement of the urine output. A client's statements and reports of symptoms
are documented as subjective data, such as the data found in options 1, 3, and 4.
When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the
following before determining whether the BP is normal or represents hypertension?
A. Compare this reading against defined standards
B. Compare the reading with one taken in the opposite arm
C. Determine gaps in the vital signs in the client record
D. Compare the current measurement with previous ones - ANSWER: A. Compare this reading against
defined
Rationale: Analysis of the client's BP requires knowledge of the normal BP range for an older adult.
The nurse compares the client's data against identified standards to determine whether this reading is
normal or abnormal. Measuring the BP in the other arm (option 2) and comparing the reading to
previous ones (option 4) will give additional client data, but the comparison alone will not determine
whether the BP is normal. Gaps in the record (option 3) will not aid in interpreting the current
measurement.
Which of the following behaviors by the nurse demonstrates that the nurse is participating in critical
thinking? Select all that apply.
A. Admitting not knowing how to do a procedure and requesting help
B. Using clever and persuasive remarks to support an opinion or position
C. Accepting without question the values acquired in nursing school
D. Finding a quick and logical answer, even to complex questions
E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs.
- ANSWER: A. Admitting not knowing how to do a procedure and requesting help
E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs.
, Rationale: Critical thinking in nursing is self-directed, supporting what nurses know and making clear
what they do not know. It is important for nurses to recognize when they lack the knowledge they
need to provide safe care for a client (option 1). Nurses must also utilize their resources to acquire the
support they need to care for a client safely (option 5). Options 2, 3, and 4 do not demonstrate critical
thinking.
The nurse has documented the following outcome goal in the care plan: "The client will transfer from
bed to chair with two-person assist." The charge nurse tells the nurse to add which of the following to
complete the goal?
A. Client behavior
B. Conditions or modifiers
C. Performance criteria
D. Target time - ANSWER: D. Target time
Rationale: The outcome goal does not state the target timeframe for when the nurse should expect to
see the client behavior ("transfer"). The condition or modifier is present ("with two assists"). The
performance criterion is "from bed to chair."
The nurse who documents on the client's care plan the outcome goal "Anxiety will be relieved within
20 to 40 minutes following administration of lorazepam (Ativan)" is engaged in which step of the
nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation - ANSWER: B. Planning
Rationale: The planning step of the nursing process involves formulating client goals and designing the
nursing interventions required to prevent, reduce, or eliminate the client's health problems. Outcome
goals are documented on the client's care plan. Assessment data (option 1) is used to help identify a
client's human response, and once a plan is established, the interventions are implemented (option 3)
and evaluated (option 4).
When the client resists taking a liquid medication that is essential to treatment, the nurse
demonstrates critical thinking by doing which of the following first?
A. Omitting this dose of medication and waiting until the client is more cooperative
B. Suggesting the medication can be diluted in a beverage
C. Asking the nurse manager about how to approach the situation
D. Notifying the physician inability to give the client this medication - ANSWER: B. Suggesting the
medication can be diluted in a beverage
Rationale: Diluting the medication in a beverage may make the medication more palatable. Using
critical thinking skills, the nurse should try to problem-solve in a situation such as this before asking
for the assistance of the nurse manager. Suggesting an alternative method of taking the medication
(provided that there are no contraindications to diluting the medication) should improve the
likelihood of the client taking the medication.
Which professionally appropriate response should the nurse make when a more stringent policy for
the use of restraints is introduced on a surgical unit?
A. Use the previous, less restrictive policy conscientiously
B. Express immediate disagreement with the new policy
C. Ask for the rationale behind the new policy
D. Obey the policy but continue to voice disapproval of it to co-workers - ANSWER: C. Ask for the
rationale behind the new policy
Test Bank - 9780323529495 All Chapters | All Chapters with
Answers and Rationals
A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the
client's vital signs, the nurse is implementing which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation - ANSWER: A. Assessment
Rationale: The first step in the nursing process is assessment, the process of collecting data. All
subsequent phases of the nursing process (options 2, 3, and 4) rely on accurate and complete data.
The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of
the following should the nurse record as objective data?
A. The client reports abdominal pain
B. The client's urine output was 450 mL
C. The client states, "I didn't see any stones in my urine."
D. The client states, "I feel like I have passed a stone." - ANSWER: B. The client's urine output was 450
mL.
Rationale: Objective data is measurable data that can be seen, heard, or verified by the nurse. The
objective data is the measurement of the urine output. A client's statements and reports of symptoms
are documented as subjective data, such as the data found in options 1, 3, and 4.
When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the
following before determining whether the BP is normal or represents hypertension?
A. Compare this reading against defined standards
B. Compare the reading with one taken in the opposite arm
C. Determine gaps in the vital signs in the client record
D. Compare the current measurement with previous ones - ANSWER: A. Compare this reading against
defined
Rationale: Analysis of the client's BP requires knowledge of the normal BP range for an older adult.
The nurse compares the client's data against identified standards to determine whether this reading is
normal or abnormal. Measuring the BP in the other arm (option 2) and comparing the reading to
previous ones (option 4) will give additional client data, but the comparison alone will not determine
whether the BP is normal. Gaps in the record (option 3) will not aid in interpreting the current
measurement.
Which of the following behaviors by the nurse demonstrates that the nurse is participating in critical
thinking? Select all that apply.
A. Admitting not knowing how to do a procedure and requesting help
B. Using clever and persuasive remarks to support an opinion or position
C. Accepting without question the values acquired in nursing school
D. Finding a quick and logical answer, even to complex questions
E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs.
- ANSWER: A. Admitting not knowing how to do a procedure and requesting help
E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs.
, Rationale: Critical thinking in nursing is self-directed, supporting what nurses know and making clear
what they do not know. It is important for nurses to recognize when they lack the knowledge they
need to provide safe care for a client (option 1). Nurses must also utilize their resources to acquire the
support they need to care for a client safely (option 5). Options 2, 3, and 4 do not demonstrate critical
thinking.
The nurse has documented the following outcome goal in the care plan: "The client will transfer from
bed to chair with two-person assist." The charge nurse tells the nurse to add which of the following to
complete the goal?
A. Client behavior
B. Conditions or modifiers
C. Performance criteria
D. Target time - ANSWER: D. Target time
Rationale: The outcome goal does not state the target timeframe for when the nurse should expect to
see the client behavior ("transfer"). The condition or modifier is present ("with two assists"). The
performance criterion is "from bed to chair."
The nurse who documents on the client's care plan the outcome goal "Anxiety will be relieved within
20 to 40 minutes following administration of lorazepam (Ativan)" is engaged in which step of the
nursing process?
A. Assessment
B. Planning
C. Implementation
D. Evaluation - ANSWER: B. Planning
Rationale: The planning step of the nursing process involves formulating client goals and designing the
nursing interventions required to prevent, reduce, or eliminate the client's health problems. Outcome
goals are documented on the client's care plan. Assessment data (option 1) is used to help identify a
client's human response, and once a plan is established, the interventions are implemented (option 3)
and evaluated (option 4).
When the client resists taking a liquid medication that is essential to treatment, the nurse
demonstrates critical thinking by doing which of the following first?
A. Omitting this dose of medication and waiting until the client is more cooperative
B. Suggesting the medication can be diluted in a beverage
C. Asking the nurse manager about how to approach the situation
D. Notifying the physician inability to give the client this medication - ANSWER: B. Suggesting the
medication can be diluted in a beverage
Rationale: Diluting the medication in a beverage may make the medication more palatable. Using
critical thinking skills, the nurse should try to problem-solve in a situation such as this before asking
for the assistance of the nurse manager. Suggesting an alternative method of taking the medication
(provided that there are no contraindications to diluting the medication) should improve the
likelihood of the client taking the medication.
Which professionally appropriate response should the nurse make when a more stringent policy for
the use of restraints is introduced on a surgical unit?
A. Use the previous, less restrictive policy conscientiously
B. Express immediate disagreement with the new policy
C. Ask for the rationale behind the new policy
D. Obey the policy but continue to voice disapproval of it to co-workers - ANSWER: C. Ask for the
rationale behind the new policy
