PRIMEXAM.COM
,Chapter 01: The Nursing Process and Drug Therapy
d d d d d d d
Lilley: Pharmacology and the Nursing Process, 10th Edition
d d d d d d d
MULTIPLE CHOICE d
1. The nurse is developing a human needs statement for a patient who has a new diagnosis of
d d d d d d d d d d d d d d d d
heart failure. Identification of human needs statements occur with which of these activities?
d d d d d d d d d d d d d
a. Collection of patient data d d d
b. Administering interventions d
c. Deciding on patient outcomes d d d
d. Documenting the patient‘s behavior d d d
ANS: A d
Identification of human needs occurs with the collection of patient data.
d d d d d d d d d d
DIF: Cognitive Level: Understanding (Comprehension) d d d
TOP: Nursing Process: Human Needs Statement
d d d d d d
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
d d d d d d d d d
2. The patient is to receive oral guaifenesin twice a day. Today, the nurse was busy and gave the
d d d d d d d d d d d d d d d d d
medication 2 hours after the scheduled dose was due. What type of problem does this
d d d d d d d d d d d d d d d
represent?
d
a. ―Right time‖ d
b. ―Right dose‖ d
c. ―Right route‖ d
d. ―Right medication‖ d
ANS: A d
―Right time‖ is correct because the medication was given more than 30 minutes after the
d d d d d d d d d d d d d d
scheduled dose was due. ―Dose‖ is incorrect because the dose is not related to the time the
d d d d d d d d d d d d d d d d d
medication administration is scheduled. ―Route‖ is incorrect because the route is not affected.
d d d d d d d d d d d d d
―Medication‖ is incorrect because the medication ordered will not change. d d d d d d d d d
DIF: Cognitive Level: Applying (Application) d d d
TOP: Nursing Process: Implementation
d d d d
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
d d d d d d d d d d
3. The nurse has been monitoring the patient‘s progress on a new drug regimen since the first
d d d d d d d d d d d d d d d
dose and documenting the patient‘s therapeutic response to the medication. Which phase of
d d d d d d d d d d d d d
the nursing process do these actions illustrate?
d d d d d d d
a. Human needs statement d d
b. Planning
c. Implementation
d. Evaluation
ANS: D d
Monitoring the patient‘s progress, including the patient‘s response to the medication, is part of
d d d d d d d d d d d d d
the evaluation phase. Planning, implementation, and human needs statement are not illustrated
d d d d d d d d d d d d
by this example.
d d d
DIF: d d Cognitive Level: Understanding (Comprehension) d d d TOP: Nursing Process: Evaluation
d d d
PRIMEXAM.COM
, MSC: NCLEX: Safe and Effective Care Environment: Management of Care
d d d d d d d d d
4. The nurse is assigned to a patient who is newly diagnosed with type 1 diabetes mellitus.
d d d d d d d d d d d d d d d
dWhich statement best illustrates an outcome criterion for this patient?
d d d d d d d d d
a. The patient will follow instructions.
d d d d
b. The patient will not experience complications.
d d d d d
c. The patient will adhere to the new insulin treatment regimen.
d d d d d d d d d
d. The patient will demonstrate correct blood glucose testing technique.
d d d d d d d d
ANS: D d
―Demonstrating correct blood glucose testing technique‖ is a specific and measurable d d d d d d d d d d
outcome criterion. ―Following instructions‖ and ―not experiencing complications‖ are not
d d d d d d d d d d
specific criteria. ―Adhering to new regimen‖ would be difficult to measure.
d d d d d d d d d d d
DIF: Cognitive Level: Applying (Application) TOP: Nursing Process: Planning
d d d d d d
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
d d d d d d d d d d
5. Which activity best reflects the implementation phase of the nursing process for the patient
d d d d d d d d d d d d d
dwho is newly diagnosed with hypertension?
d d d d d
a. Providing education on keeping a journal of blood pressure readings
d d d d d d d d d
b. Setting goals and outcome criteria with the patient‘s input
d d d d d d d d
c. Recording a drug history regarding over-the-counter medications used at home
d d d d d d d d d
d. Formulating human needs statements regarding deficient knowledge related to the d d d d d d d d d
new treatment regimen
d d d
ANS: A d
Education is an intervention that occurs during the implementation phase. Setting goals and
d d d d d d d d d d d d
outcomes reflects the planning phase. Recording a drug history reflects the assessment phase.
d d d d d d d d d d d d d
Formulating human needs statements reflects analysis of data as part of planning.
d d d d d d d d d d d d
DIF: Cognitive Level: Applying (Application) d d d
TOP: Nursing Process: Implementation
d d d d
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
d d d d d d d d d
6. The medication order reads, ―Give ondansetron 4 mg, 30 minutes before beginning
d d d d d d d d d d d
chemotherapy to prevent nausea.‖ The nurse notes that the route is missing from the order.
d d d d d d d d d d d d d d d
What is the nurse‘s best action?
d d d d d d
a. Give the medication intravenously because the patient might vomit.
d d d d d d d d
b. Give the medication orally because the tablets are available in 4-mg doses.
d d d d d d d d d d d
c. Contact the prescriber to clarify the route of the medication ordered.
d d d d d d d d d d
d. Hold the medication until the prescriber returns to make rounds.
d d d d d d d d d
ANS: C d
A complete medication order includes the route of administration. If a medication order does
d d d d d d d d d d d d d
not include the route, the nurse must ask the prescriber to clarify it. The intravenous and oral
d d d d d d d d d d d d d d d d d
routes are not interchangeable. Holding the medication until the prescriber returns would
d d d d d d d d d d d d
mean that the patient would not receive a needed medication.
d d d d d d d d d d
DIF: Cognitive Level: Applying (Application) d d d
TOP: Nursing Process: Implementation
d d d d
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
d d d d d d d d d
PRIMEXAM.COM
, 7. When the nurse considers the timing of a drug dose, which factor is appropriate to consider
d d d d d d d d d d d d d d d
dwhen deciding when to give a drug?
d d d d d d
a. The patient‘s ability to swallow
d d d d
b. The patient‘s height d d
c. The patient‘s last meal d d d
d. The patient‘s allergies d d
ANS: C d
The nurse must consider specific pharmacokinetic/pharmacodynamic drug properties that may
d d d d d d d d d
be affected by the timing of the last meal. The patient‘s ability to swallow, height, and
d d d d d d d d d d d d d d d d
allergies are not factors to consider regarding the timing of the drug‘s administration.
d d d d d d d d d d d d d
DIF: Cognitive Level: Understanding (Comprehension) d d d
TOP: Nursing Process: Assessment
d d d d
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
d d d d d d d d d
8. The nurse is performing an assessment of a newly admitted patient. Which is an example of
d d d d d d d d d d d d d d d
dsubjective data? d
a. Weight 155 pounds d d
b. Pulse 72 beats/minute d d
c. The patient reports that he uses the herbal product ginkgo
d d d d d d d d d
d. The patient‘s complete blood count results
d d d d d
ANS: C d
Subjective data include information shared through the spoken word by any reliable source,
d d d d d d d d d d d d
such as the patient. Objective data may be defined as any information gathered through the
d d d d d d d d d d d d d d d
senses or that which is seen, heard, felt, or smelled. A patient‘s pulse, weight, and laboratory
d d d d d d d d d d d d d d d d
tests are all examples of objective data.
d d d d d d d
DIF: Cognitive Level: Understanding (Comprehension) d d d
TOP: Nursing Process: Assessment
d d d d
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
d d d d d d d d d
MULTIPLE RESPONSE d
1. When giving medications, the nurse will follow the rights of medication administration. The
d d d d d d d d d d d d
drights include the right documentation, the right reason, the right response, and the patient‘s
d d d d d d d d d d d d d
dright to refuse. Which of these are additional rights? (Select all that apply.)
d d d d d d d d d d d d
a. Right drug d
b. Right route d
c. Right dose d
d. Right diagnosis d
e. Right time d
f. Right patient d
ANS: A, B, C, E, F
d d d d d
Additional rights of medication administration must always include the right drug, right dose,
d d d d d d d d d d d d
right time, right route, and right patient. The right diagnosis is incorrect.
d d d d d d d d d d d d
DIF: Cognitive Level: Remembering (Knowledge) d d d
TOP: Nursing Process: Implementation
d d d d
PRIMEXAM.COM
,Chapter 01: The Nursing Process and Drug Therapy
d d d d d d d
Lilley: Pharmacology and the Nursing Process, 10th Edition
d d d d d d d
MULTIPLE CHOICE d
1. The nurse is developing a human needs statement for a patient who has a new diagnosis of
d d d d d d d d d d d d d d d d
heart failure. Identification of human needs statements occur with which of these activities?
d d d d d d d d d d d d d
a. Collection of patient data d d d
b. Administering interventions d
c. Deciding on patient outcomes d d d
d. Documenting the patient‘s behavior d d d
ANS: A d
Identification of human needs occurs with the collection of patient data.
d d d d d d d d d d
DIF: Cognitive Level: Understanding (Comprehension) d d d
TOP: Nursing Process: Human Needs Statement
d d d d d d
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
d d d d d d d d d
2. The patient is to receive oral guaifenesin twice a day. Today, the nurse was busy and gave the
d d d d d d d d d d d d d d d d d
medication 2 hours after the scheduled dose was due. What type of problem does this
d d d d d d d d d d d d d d d
represent?
d
a. ―Right time‖ d
b. ―Right dose‖ d
c. ―Right route‖ d
d. ―Right medication‖ d
ANS: A d
―Right time‖ is correct because the medication was given more than 30 minutes after the
d d d d d d d d d d d d d d
scheduled dose was due. ―Dose‖ is incorrect because the dose is not related to the time the
d d d d d d d d d d d d d d d d d
medication administration is scheduled. ―Route‖ is incorrect because the route is not affected.
d d d d d d d d d d d d d
―Medication‖ is incorrect because the medication ordered will not change. d d d d d d d d d
DIF: Cognitive Level: Applying (Application) d d d
TOP: Nursing Process: Implementation
d d d d
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
d d d d d d d d d d
3. The nurse has been monitoring the patient‘s progress on a new drug regimen since the first
d d d d d d d d d d d d d d d
dose and documenting the patient‘s therapeutic response to the medication. Which phase of
d d d d d d d d d d d d d
the nursing process do these actions illustrate?
d d d d d d d
a. Human needs statement d d
b. Planning
c. Implementation
d. Evaluation
ANS: D d
Monitoring the patient‘s progress, including the patient‘s response to the medication, is part of
d d d d d d d d d d d d d
the evaluation phase. Planning, implementation, and human needs statement are not illustrated
d d d d d d d d d d d d
by this example.
d d d
DIF: d d Cognitive Level: Understanding (Comprehension) d d d TOP: Nursing Process: Evaluation
d d d
PRIMEXAM.COM
, MSC: NCLEX: Safe and Effective Care Environment: Management of Care
d d d d d d d d d
4. The nurse is assigned to a patient who is newly diagnosed with type 1 diabetes mellitus.
d d d d d d d d d d d d d d d
dWhich statement best illustrates an outcome criterion for this patient?
d d d d d d d d d
a. The patient will follow instructions.
d d d d
b. The patient will not experience complications.
d d d d d
c. The patient will adhere to the new insulin treatment regimen.
d d d d d d d d d
d. The patient will demonstrate correct blood glucose testing technique.
d d d d d d d d
ANS: D d
―Demonstrating correct blood glucose testing technique‖ is a specific and measurable d d d d d d d d d d
outcome criterion. ―Following instructions‖ and ―not experiencing complications‖ are not
d d d d d d d d d d
specific criteria. ―Adhering to new regimen‖ would be difficult to measure.
d d d d d d d d d d d
DIF: Cognitive Level: Applying (Application) TOP: Nursing Process: Planning
d d d d d d
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
d d d d d d d d d d
5. Which activity best reflects the implementation phase of the nursing process for the patient
d d d d d d d d d d d d d
dwho is newly diagnosed with hypertension?
d d d d d
a. Providing education on keeping a journal of blood pressure readings
d d d d d d d d d
b. Setting goals and outcome criteria with the patient‘s input
d d d d d d d d
c. Recording a drug history regarding over-the-counter medications used at home
d d d d d d d d d
d. Formulating human needs statements regarding deficient knowledge related to the d d d d d d d d d
new treatment regimen
d d d
ANS: A d
Education is an intervention that occurs during the implementation phase. Setting goals and
d d d d d d d d d d d d
outcomes reflects the planning phase. Recording a drug history reflects the assessment phase.
d d d d d d d d d d d d d
Formulating human needs statements reflects analysis of data as part of planning.
d d d d d d d d d d d d
DIF: Cognitive Level: Applying (Application) d d d
TOP: Nursing Process: Implementation
d d d d
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
d d d d d d d d d
6. The medication order reads, ―Give ondansetron 4 mg, 30 minutes before beginning
d d d d d d d d d d d
chemotherapy to prevent nausea.‖ The nurse notes that the route is missing from the order.
d d d d d d d d d d d d d d d
What is the nurse‘s best action?
d d d d d d
a. Give the medication intravenously because the patient might vomit.
d d d d d d d d
b. Give the medication orally because the tablets are available in 4-mg doses.
d d d d d d d d d d d
c. Contact the prescriber to clarify the route of the medication ordered.
d d d d d d d d d d
d. Hold the medication until the prescriber returns to make rounds.
d d d d d d d d d
ANS: C d
A complete medication order includes the route of administration. If a medication order does
d d d d d d d d d d d d d
not include the route, the nurse must ask the prescriber to clarify it. The intravenous and oral
d d d d d d d d d d d d d d d d d
routes are not interchangeable. Holding the medication until the prescriber returns would
d d d d d d d d d d d d
mean that the patient would not receive a needed medication.
d d d d d d d d d d
DIF: Cognitive Level: Applying (Application) d d d
TOP: Nursing Process: Implementation
d d d d
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
d d d d d d d d d
PRIMEXAM.COM
, 7. When the nurse considers the timing of a drug dose, which factor is appropriate to consider
d d d d d d d d d d d d d d d
dwhen deciding when to give a drug?
d d d d d d
a. The patient‘s ability to swallow
d d d d
b. The patient‘s height d d
c. The patient‘s last meal d d d
d. The patient‘s allergies d d
ANS: C d
The nurse must consider specific pharmacokinetic/pharmacodynamic drug properties that may
d d d d d d d d d
be affected by the timing of the last meal. The patient‘s ability to swallow, height, and
d d d d d d d d d d d d d d d d
allergies are not factors to consider regarding the timing of the drug‘s administration.
d d d d d d d d d d d d d
DIF: Cognitive Level: Understanding (Comprehension) d d d
TOP: Nursing Process: Assessment
d d d d
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
d d d d d d d d d
8. The nurse is performing an assessment of a newly admitted patient. Which is an example of
d d d d d d d d d d d d d d d
dsubjective data? d
a. Weight 155 pounds d d
b. Pulse 72 beats/minute d d
c. The patient reports that he uses the herbal product ginkgo
d d d d d d d d d
d. The patient‘s complete blood count results
d d d d d
ANS: C d
Subjective data include information shared through the spoken word by any reliable source,
d d d d d d d d d d d d
such as the patient. Objective data may be defined as any information gathered through the
d d d d d d d d d d d d d d d
senses or that which is seen, heard, felt, or smelled. A patient‘s pulse, weight, and laboratory
d d d d d d d d d d d d d d d d
tests are all examples of objective data.
d d d d d d d
DIF: Cognitive Level: Understanding (Comprehension) d d d
TOP: Nursing Process: Assessment
d d d d
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
d d d d d d d d d
MULTIPLE RESPONSE d
1. When giving medications, the nurse will follow the rights of medication administration. The
d d d d d d d d d d d d
drights include the right documentation, the right reason, the right response, and the patient‘s
d d d d d d d d d d d d d
dright to refuse. Which of these are additional rights? (Select all that apply.)
d d d d d d d d d d d d
a. Right drug d
b. Right route d
c. Right dose d
d. Right diagnosis d
e. Right time d
f. Right patient d
ANS: A, B, C, E, F
d d d d d
Additional rights of medication administration must always include the right drug, right dose,
d d d d d d d d d d d d
right time, right route, and right patient. The right diagnosis is incorrect.
d d d d d d d d d d d d
DIF: Cognitive Level: Remembering (Knowledge) d d d
TOP: Nursing Process: Implementation
d d d d
PRIMEXAM.COM
