,Chapter .01: .The .Nursing .Process .and .Drug .Therapy
.Lilley: .Pharmacology .and .the .Nursing .Process, .8th
.Edition
MULTIPLE .CHOICE
1. The .nurse .is .writing .a .nursing .diagnosis .for .a .plan .of .care .for .a .patient .who .has .been
.newly .diagnosed .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 .statement .beginning .―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) REF: . p.
.7 .TOP: . NURSING .PROCESS: .Nursing .Diagnosis
MSC: . NCLEX: .Safe .and .Effective .Care .Environment: .Management .of .Care
2. The .patient .is .to .receive .oral .guaifenesin .(Mucinex) .twice .a .day. .Today, .the .nurse .was
.busy .and .gave .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
.scheduled .dose .was .due. .―Dose‖ .is .incorrect .because .the .dose .is .not .related .to .the .time .the
.medication .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) REF: . p.
.11 .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. Nursing .diagnosis
b. Planning
, c. Implementation
d. Evaluation
ANS: . D
Monitoring .the .patient‘s .progress, .including .the .patient‘s .response .to .the .medication, .is .part
.of .the .evaluation .phase. .Planning, .implementation, .and .nursing .diagnosis .are .not .illustrated
.by .this .example.
DIF: COGNITIVE .LEVEL: .Understanding .(Comprehension) REF: . pp. .13-
14 .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
.mellitus. .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 .not
.specific .criteria. .―Adhering .to .new .regimen‖ .would .be .difficult .to .measure.
DIF: COGNITIVE .LEVEL: .Applying .(Application) REF: . p.
.8 .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
.patient .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 .nursing .diagnoses .regarding .deficient .knowledge .related .to .the
.new .treatment .regimen
ANS: . A
Education .is .an .intervention .that .occurs .during .the .implementation .phase. .Setting .goals .and
.outcomes .reflects .the .planning .phase. .Recording .a .drug .history .reflects .the .assessment
.phase. .Formulating .nursing .diagnoses .reflects .analysis .of .data .as .part .of .planning.
DIF: COGNITIVE .LEVEL: .Applying .(Application) REF: . pp. .8-
9 .TOP: . NURSING .PROCESS: .Implementation
MSC: . NCLEX: .Safe .and .Effective .Care .Environment: .Management .of .Care
6. The .medication .order .reads, .―Give .ondansetron .(Zofran) .4 .mg, .30 .minutes .before
.beginning .chemotherapy .to .prevent .nausea.‖ .The .nurse .notes .that .the .route .is .missing
.from .the .order. .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
.does .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
.returns .would .mean .that .the .patient .would .not .receive .a .needed .medication.
DIF: COGNITIVE .LEVEL: .Applying .(Application) REF: . p.
.12 .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
.consider .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,
.and .allergies .are .not .factors .to .consider .regarding .the .timing .of .the .drug‘s .administration.
DIF: COGNITIVE .LEVEL: .Understanding .(Comprehension) REF: . p.
.12 .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 .example
.of .subjective .data?
a. Blood .pressure .158/96 .mm .Hg
b. Weight .255 .pounds
c. The .patient .reports .that .he .uses .the .herbal .product .ginkgo.
d. The .patient‘s .laboratory .work .includes .a .complete .blood .count .and .urinalysis.
ANS: . C
Subjective .data .include .information .shared .through .the .spoken .word .by .any .reliable .source,
.such .as .the .patient. .Objective .data .may .be .defined .as .any .information .gathered .through .the
.senses .or .that .which .is .seen, .heard, .felt, .or .smelled. .A .patient‘s .blood .pressure, .weight, .and
.laboratory .tests .are .all .examples .of .objective .data.
DIF: COGNITIVE .LEVEL: .Understanding .(Comprehension) REF: . p.
.6 .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
.Lilley: .Pharmacology .and .the .Nursing .Process, .8th
.Edition
MULTIPLE .CHOICE
1. The .nurse .is .writing .a .nursing .diagnosis .for .a .plan .of .care .for .a .patient .who .has .been
.newly .diagnosed .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 .statement .beginning .―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) REF: . p.
.7 .TOP: . NURSING .PROCESS: .Nursing .Diagnosis
MSC: . NCLEX: .Safe .and .Effective .Care .Environment: .Management .of .Care
2. The .patient .is .to .receive .oral .guaifenesin .(Mucinex) .twice .a .day. .Today, .the .nurse .was
.busy .and .gave .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
.scheduled .dose .was .due. .―Dose‖ .is .incorrect .because .the .dose .is .not .related .to .the .time .the
.medication .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) REF: . p.
.11 .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. Nursing .diagnosis
b. Planning
, c. Implementation
d. Evaluation
ANS: . D
Monitoring .the .patient‘s .progress, .including .the .patient‘s .response .to .the .medication, .is .part
.of .the .evaluation .phase. .Planning, .implementation, .and .nursing .diagnosis .are .not .illustrated
.by .this .example.
DIF: COGNITIVE .LEVEL: .Understanding .(Comprehension) REF: . pp. .13-
14 .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
.mellitus. .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 .not
.specific .criteria. .―Adhering .to .new .regimen‖ .would .be .difficult .to .measure.
DIF: COGNITIVE .LEVEL: .Applying .(Application) REF: . p.
.8 .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
.patient .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 .nursing .diagnoses .regarding .deficient .knowledge .related .to .the
.new .treatment .regimen
ANS: . A
Education .is .an .intervention .that .occurs .during .the .implementation .phase. .Setting .goals .and
.outcomes .reflects .the .planning .phase. .Recording .a .drug .history .reflects .the .assessment
.phase. .Formulating .nursing .diagnoses .reflects .analysis .of .data .as .part .of .planning.
DIF: COGNITIVE .LEVEL: .Applying .(Application) REF: . pp. .8-
9 .TOP: . NURSING .PROCESS: .Implementation
MSC: . NCLEX: .Safe .and .Effective .Care .Environment: .Management .of .Care
6. The .medication .order .reads, .―Give .ondansetron .(Zofran) .4 .mg, .30 .minutes .before
.beginning .chemotherapy .to .prevent .nausea.‖ .The .nurse .notes .that .the .route .is .missing
.from .the .order. .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
.does .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
.returns .would .mean .that .the .patient .would .not .receive .a .needed .medication.
DIF: COGNITIVE .LEVEL: .Applying .(Application) REF: . p.
.12 .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
.consider .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,
.and .allergies .are .not .factors .to .consider .regarding .the .timing .of .the .drug‘s .administration.
DIF: COGNITIVE .LEVEL: .Understanding .(Comprehension) REF: . p.
.12 .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 .example
.of .subjective .data?
a. Blood .pressure .158/96 .mm .Hg
b. Weight .255 .pounds
c. The .patient .reports .that .he .uses .the .herbal .product .ginkgo.
d. The .patient‘s .laboratory .work .includes .a .complete .blood .count .and .urinalysis.
ANS: . C
Subjective .data .include .information .shared .through .the .spoken .word .by .any .reliable .source,
.such .as .the .patient. .Objective .data .may .be .defined .as .any .information .gathered .through .the
.senses .or .that .which .is .seen, .heard, .felt, .or .smelled. .A .patient‘s .blood .pressure, .weight, .and
.laboratory .tests .are .all .examples .of .objective .data.
DIF: COGNITIVE .LEVEL: .Understanding .(Comprehension) REF: . p.
.6 .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
