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Basic Pharmacology for Nurses 16th Edition by Clayton – Willihnganz-Test Bank
Sample Questions
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Chapter 2: Basic Principles of Drug Action and Drug Interactions
Test Bank
MULTIPLE CHOICE
- The nurse assesses hives in a patient started on a new medication. What is the nurse’s priority action?
| a. | Notify physician of allergic reaction. |
| b. | Notify physician of idiosyncratic reaction. |
| c. | Notify physician of potential teratogenicity. |
| d. | Notify physician of potential tolerance. |
ANS: A
An allergic reaction is indicative of hypersensitivity and manifests with hives and/or urticaria, which are easily identified. An idiosyncratic reaction occurs when something unusual or abnormal happens when a drug is first administered. A teratogenic reaction refers to the occurrence of birth defects related to administration of the drug. Tolerance refers to the body’s requirement for increasing dosages to achieve the same effects that a lower dose once did.
DIF: Cognitive Level: Application REF: p. 17 OBJ: 7
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse administers an initial dose of a steroid to a patient with asthma. Thirty minutes after administration, the nurse finds the patient agitated and stating that “everyone is out to get me.” What is the term for this unusual reaction?
| a. | Desired action |
| b. | Adverse effect |
| c. | Idiosyncratic reaction |
| d. | Allergic reaction |
ANS: C
Idiosyncratic reactions are unusual, abnormal reactions that occur when a drug is first administered. Patients typically exhibit an overresponsiveness to a medication related to diminished metabolism. These reactions are believed to be related to genetic enzyme deficiencies. Desired actions are expected responses to a medication. Adverse effects are reactions that occur in another system of the body; they are usually predictable. Allergic reactions appear after repeated medication dosages.
DIF: Cognitive Level: Comprehension REF: p. 17 OBJ: 7
TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity
- Which is the best description of when drug interactions occur?
| a. | On administration of toxic dosages of a drug |
| b. | On an increase in the pharmacodynamics of bound drugs |
| c. | On the alteration of the effect of one drug by another drug |
| d. | On increase of drug excretion |
ANS: C
Drug interactions may be characterized by an increase or decrease in the effectiveness of one or both of the drugs. Toxicity of one drug may or may not affect the metabolism of another one. Drug interactions may result from either increased or decreased pharmacodynamics. Drug interactions may result from either increased or decreased excretion.
DIF: Cognitive Level: Comprehension REF: p. 17 OBJ: 8
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- What occurs when two drugs compete for the same receptor site, resulting in increased activity of the first drug?
| a. | Desired action |
| b. | Synergistic effect |
| c. | Carcinogenicity |
| d. | Displacement |
ANS: D
The displacement of the first drug from receptor sites by a second drug increases the amount of the first drug because more unbound drug is available. An expected response of a drug is the desired action. A synergistic effect is the effect of two drugs being greater than the effect of each chemical individually, or the sum of the individual effects. Carcinogenicity is the ability of a drug to cause cells to mutate and become cancerous.
DIF: Cognitive Level: Comprehension REF: p. 17 OBJ: 9
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- What do drug blood levels indicate?
| a. | They confirm if the patient is taking a generic form of a drug. |
| b. | They determine if the patient has sufficient body fat to metabolize the drug. |
| c. | They verify if the patient is taking someone else’s medications. |
| d. | They determine if the amount of drug in the body is in a therapeutic range. |
ANS: D
The amount of drug present may vary over time and the blood level must remain in a therapeutic range in order to obtain the desired result. Generic drugs do not necessarily produce a different drug blood level than proprietary medications. Body fat is not measured by drug blood levels. Drug blood levels only measure the amount of drug in the body; they do not determine the source of the medication.
DIF: Cognitive Level: Comprehension REF: p. 16 OBJ: 7
TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity
- What is the process by which a drug is transported by circulating body fluids to receptor sites?
| a. | Osmosis |
| b. | Distribution |
| c. | Absorption |
| d. | Biotransformation |
ANS: B
Distribution refers to the ways in which drugs are transported by the circulating body fluids to the sites of action (receptors), metabolism, and excretion. Osmosis is the process of moving solution across a semipermeable membrane to equalize the dilution on each side. Absorption is the process by which a drug is transferred from its site of entry into the body to the circulating fluids for distribution. Biotransformation, also called metabolism, is the process by which the body inactivates drugs.
DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: 4
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse assesses which blood level to determine the amount of circulating medication in a patient?
| a. | Peak |
| b. | Trough |
| c. | Drug |
| d. | Therapeutic |
ANS: C
When a drug is circulating in the blood, a blood sample may be drawn and assayed to determine the amount of drug present; this is known as the drug blood level. Peak levels are only those drug blood levels that are at their maximum before metabolism starts to decrease the amount of circulating drug. Trough levels are only those drug blood levels that are at their minimum when metabolism has decreased the amount of circulating drug and before an increase caused by a subsequent dose of the medication. Therapeutic levels are only those within a prescribed range of blood levels determined to bring about effective action of the medication.
DIF: Cognitive Level: Comprehension REF: p. 16 OBJ: 7
TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse administers 50 mg of a drug at 6:00 AM that has a half life of 8 hours. What time will it be when 25 mg of the drug has been eliminated from the body?
| a. | 8:00 AM |
| b. | 11:00 AM |
| c. | 2:00 PM |
| d. | 6:00 PM |
ANS: C
Fifty percent of the medication, or 25 mg, will be eliminated in 8 hours, or at 2:00 PM. 8:00 AM is 2 hours after administration; the half life is 8 hours. 11:00 AM is 4 hours after administration; the half life is 8 hours. 6:00 PM is 12 hours after administration; the half life is 8 hours.
DIF: Cognitive Level: Analysis REF: p. 14 OBJ: 6
TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity
- What will the nurse need to determine first in order to mix two drugs in the same syringe?
| a. | Absorption rate of the drugs |
| b. | Compatibility of the drugs |
| c. | Drug blood level of each drug |
| d. | Medication adverse effects |
ANS: B
Knowledge of absorption is important but not in order to mix drugs. In order to mix two drugs, compatibility is determined so there is no deterioration when the drugs are mixed in the same syringe. Drug level does not indicate if it is acceptable to mix medications in the same syringe. Adverse effects are important for the nurse to know, but not in order to mix drugs.
DIF: Cognitive Level: Application REF: p. 18 OBJ: 9
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- A patient developed hives and itching after receiving a drug for the first time. Which instruction by the nurse is accurate?
| a. | Stop the medication and encourage the patient to wear a medical alert bracelet that explains the allergy. |
| b. | Explain to the patient that these are signs and symptoms of an anaphylactic reaction. |
| c. | Emphasize to the patient the importance to inform medical personnel that in the future a lower dosage of this drug is necessary. |
| d. | Instruct the patient that it would be safe to take the drug again because this instance was a mild reaction. |
ANS: A
This initial allergic reaction is mild, and the patient is more likely to have an anaphylactic reaction at the next exposure; a medical alert bracelet is necessary to explain the reaction. Signs and symptoms of an anaphylactic reaction are respiratory distress and cardiovascular collapse. A more severe reaction will occur at the next exposure, and the patient should not receive the drug again.
DIF: Cognitive Level: Application REF: p. 17 OBJ: 7
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- When obtaining a patient’s health history, which assessment data would the nurse identify as having the most effect on drug metabolism?
| a. | History of liver disease |
| b. | Intake of a vegetarian diet |
| c. | Sedentary lifestyle |
| d. | Teacher as an occupation |
ANS: A
Liver enzyme systems are the primary site for metabolism of drugs. Intake of a vegetarian diet may affect absorption but not metabolism. Sedentary lifestyle and occupations could affect metabolism (exposure to environmental pollutants), but these do not have the most significant effect on metabolism.
DIF: Cognitive Level: Application REF: p. 14 OBJ: 5
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- A physician’s order indicates to administer a medication to the patient via the percutaneous route. The nurse can anticipate that the patient will receive this medication:
| a. | intramuscularly. |
| b. | subcutaneously. |
| c. | topically. |
| d. | rectally. |
ANS: C
The percutaneous route refers to drugs that are absorbed through the skin and mucous membranes. Methods of the percutaneous route include inhalation, sublingual (under the tongue), or topical (on the skin) administration. The parenteral route bypasses the gastrointestinal (GI) tract by using subcutaneous (subcut), intramuscular (IM), or intravenous (IV) injection. The parenteral route bypasses the GI tract by using subcut, IM, or IV injection. In the enteral route, the drug is administered directly into the GI tract by the oral, rectal, or nasogastric route.
DIF: Cognitive Level: Application REF: p. 12 OBJ: 1
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- A nurse is preparing to administer tetracycline to a patient diagnosed with an infection. Which medication should not be administered with tetracycline?
| a. | Ativan |
| b. | Tylenol |
| c. | Colace |
| d. | Mylanta |
ANS: D
Administering tetracycline with Mylanta can provide an antagonistic effect that will result in decreased absorption of the tetracycline. Ativan, Tylenol, and Colace are not contraindicated to administer with tetracycline.
DIF: Cognitive Level: Application REF: p. 18 OBJ: 9
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
MULTIPLE RESPONSE
- Which statement(s) about liberation of drugs is/are true? (Select all that apply.)
| a. | A drug must be dissolved in body fluids before it can be absorbed into body
tissues. |
| b. | A solid drug taken orally must disintegrate and dissolve in GI fluids to allow for absorption into the bloodstream for transport to the site of action. |
| c. | The process of converting the drug into a soluble form can be controlled to a certain degree by the dosage form. |
| d. | Converting the drug to a soluble form can be influenced by administering the drug with or without food in the patient’s stomach. |
| e. | Elixirs take longer to be liberated from the dosage form. |
ANS: A, B, C, D
Regardless of the route of administration, a drug must be dissolved in body fluids before it can be absorbed into body tissues. Before a solid drug taken orally can be absorbed into the bloodstream for transport to the site of action, it must disintegrate and dissolve in the GI fluids and be transported across the stomach or intestinal lining into the blood. The process of converting a drug into a soluble form can be partially controlled by the pharmaceutical dosage form used (e.g., solution, suspension, capsules, and tablets with various coatings). The conversion process can also be influenced by administering the drug with or without food in the patient’s stomach. Elixirs are already drugs dissolved in a liquid and do not need to be liberated from the dosage form.
DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: 3
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- Which are routes of drug excretion? (Select all that apply.)
| a. | GI tract; feces |
| b. | Genitourinary (GU) tract; urine |
| c. | Lymphatic system |
| d. | Circulatory system; blood/plasma |
| e. | Respiratory system; exhalation |
ANS: A, B, E
The GI system is a primary route for drug excretion. The GU and the respiratory systems do function in the excretion of drugs. The lymphatic and circulatory systems are involved with drug distribution, not drug excretion.
DIF: Cognitive Level: Knowledge REF: p. 14 OBJ: 5
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Which route(s) enable(s) drug absorption more rapidly than the subcut route? (Select all that apply.)
| a. | IV route |
| b. | IM route |
| c. | Inhalation/sublingual |
| d. | Intradermal route |
| e. | Enteral route |
ANS: A, B, C
IV route of administration enables drug absorption more rapidly than the subcut route. IM route of administration enables drug absorption more rapidly because of greater blood flow per unit weight of muscle. Inhalation/sublingual route of administration enables drug absorption more rapidly than the subcut route. Intradermally administered drugs are absorbed more slowly because of the limited available blood supply in the dermis. Enterally administered drugs are absorbed more slowly because of the biotransformation process.
DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: 1
TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse recognizes that which factor(s) would contribute to digoxin toxicity in a 92-year-old patient? (Select all that apply.)
| a. | Taking the medication with meals |
| b. | Prolonged half life of the drug digoxin |
| c. | Impaired renal function |
| d. | Diminished mental capacity |
ANS: B, C
Impaired renal and hepatic function in older adults impairs metabolism and excretion of drugs, thus prolonging the half life of a medication. Food would decrease the absorption of the drug. Diminished mental capacity does not contribute to drug toxicity unless it is due to administration errors.
DIF: Cognitive Level: Application REF: p. 14 OBJ: 5 | 6
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Health Promotion and Maintenance
- Which statement(s) about variables that influence drug action is/are true? (Select all that apply.)
| a. | An older adult will require increased dosage of a drug to achieve the same therapeutic effect as that seen in a younger person. |
| b. | Body weight can affect the therapeutic response of a medication. |
| c. | Chronic smokers may metabolize drugs more rapidly than nonsmokers. |
| d. | A patient’s attitude and expectations affect the response to medication. |
| e. | Reduced circulation causes drugs to absorb more rapidly. |
ANS: B, C, D
Body weight can affect response to medications; typically, obese patients require an increase in dosage and underweight patients a decrease in dosage. Chronic smoking enhances metabolism of drugs. Attitudes and expectations play a major role in an individual’s response to drugs. Older adults require decreased dosages of drugs to achieve a therapeutic effect. Decreased circulation causes drugs to absorb more slowly.
DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: N/A
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
- Which factor(s) affect(s) drug actions? (Select all that apply.)
| a. | Teratogenicity |
| b. | Age |
| c. | Body weight |
| d. | Metabolic rate |
| e. | Illness |
ANS: B, C, D, E
Age, body weight, metabolic rate, and illness may contribute to a variable response to a medication. Teratogenicity does not contribute to a variable response to a medication.
DIF: Cognitive Level: Comprehension REF: p. 14 OBJ: N/A
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
OTHER
- A patient receives 200 mg of a medication that has a half life of 12 hours. How many mg of the drug would remain in the patient’s after 24 hours?
ANS:
50
The half life is defined as the amount of time required for 50% of the drug to be eliminated from the body. If a patient is given 200 mg of a drug that has a half life of 12 hours, then 50 mg of the drug would remain in the body after 24 hours.
DIF: Cognitive Level: Analysis REF: p. 14 OBJ: 6
TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity
Chapter 4: The Nursing Process and Pharmacology
Test Bank
MULTIPLE CHOICE
- What is the primary purpose of the nursing assessment?
| a. | Identifying underlying pathologic conditions |
| b. | Assisting the physician in identifying medical conditions |
| c. | Determining the patient’s mental status |
| d. | Exploring patient responses to health problems |
ANS: D
A nursing assessment is done to identify the patient’s response to health problems. During the nursing assessment phase, a comprehensive information base is developed through a physical examination, nursing history, medication history, and professional observation. Identifying underlying pathologic conditions and assisting the physician in identifying medical conditions is not part of the nursing process. Determining the patient’s mental status is one part of the nursing assessment, but it is not the primary purpose.
DIF: Cognitive Level: Comprehension REF: p. 36 OBJ: 1 | 3
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Health Promotion and Maintenance
- What is the basis of the NANDA I taxonomy?
| a. | Functional health patterns |
| b. | Human response patterns |
| c. | Basic human needs |
| d. | Pathophysiologic needs |
ANS: B
The NANDA I taxonomy identifies human response patterns. Functional components of health patterns are limited to activity, fluid volume, nutrition, self care, and sensory perception. Basic human needs comprise less than merely health patterns. Pathophysiologic needs are not part of the scope of NANDA I.
DIF: Cognitive Level: Knowledge REF: pp. 37-38 OBJ: 5
TOP: Nursing Process Step: Diagnosis
MSC: NCLEX Client Needs Category: Physiological Integrity
- Which task is included in the assessment step of the nursing process?
| a. | Establishing patient goals/outcomes |
| b. | Implementing the nursing care plan (NCP) |
| c. | Measuring goal/outcome achievement |
| d. | Collecting and communicating data |
ANS: D
Data are collected and communicated in the assessment phase of the nursing process. Establishing goals is the function of planning. Implementing the NCP is the function of implementation. Measuring outcome achievement is the function of evaluation.
DIF: Cognitive Level: Comprehension REF: p. 36 OBJ: 2 | 3
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Health Promotion and Maintenance
- Which statement regarding nursing diagnoses is accurate?
| a. | Nursing diagnoses remain the same for as long as the disease is present. |
| b. | Nursing diagnoses are written to identify disease states. |
| c. | Nursing diagnoses describe patient problems that nurses treat. |
| d. | Nursing diagnoses identify causes related to illness. |
ANS: C
Diagnostic statements identify problems a nurse is independently able to treat within the scope of professional practice. Nursing diagnoses vary with the changing condition of the patient. The response patterns are unique to the patient and are not disease specific. Nursing diagnoses describe the patient’s human response pattern.
DIF: Cognitive Level: Comprehension REF: pp. 37-38 OBJ: 5
TOP: Nursing Process Step: Diagnosis
MSC: NCLEX Client Needs Category: Physiological Integrity
- What do the classification systems NIC and NOC provide?
| a. | Individualized data banks of treatments related to disease processes |
| b. | Standardized language for reporting and analyzing nursing care delivery |
| c. | A measure for cost containment within medical institutions |
| d. | Specialized interventions for rare diseases |
ANS: B
Nursing classification systems such as NIC and NOC are designed to provide a standardized language for reporting and analyzing nursing care delivery that is individualized for each patient. Standardized terminology assists practitioners in the implementation of the five phases of the nursing process. Classification systems are not related to disease process and are not used for financial purposes. Classification systems include interventions for all health conditions.
DIF: Cognitive Level: Knowledge REF: p. 34 OBJ: 11
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe, Effective Care Environment
- Which type of nursing diagnosis will be written when the patient exhibits factors that makes him or her susceptible to the development of a problem?
| a. | Actual diagnosis |
| b. | Risk diagnosis |
| c. | Possible diagnosis |
| d. | Wellness diagnosis |
ANS: B
When patients have the potential or risk for a problem to develop, a risk diagnosis is written. These diagnoses are two part statements such as Risk for falls related to unsteady gait. An actual diagnosis consists of a NANDA diagnostic label, contributing factor (if known), and defining characteristics such as signs and symptoms. A possible nursing diagnosis identifies a problem that may occur, but the assembled data are insufficient to confirm it. A wellness diagnosis applies to individuals for whom an enhanced level of wellness is possible.
DIF: Cognitive Level: Comprehension REF: p. 38 OBJ: 5
TOP: Nursing Process Step: Diagnosis
MSC: NCLEX Client Needs Category: Physiological Integrity
- Which outcome statement identified by the nurse is written correctly?
| a. | After surgery, patient will express acceptance of loss of breast. |
| b. | Patient will die with dignity. |
| c. | At the end of the shift, the nurse will determine whether the patient is more comfortable. |
| d. | Within the next 8 hours, urine output will be greater than 30 mL/hr. |
ANS: D
The statement, “Within the next 8 hours, urine output will be greater than 30 mL/hr” is patient oriented, realistic, and measurable, and has an appropriate time frame.
DIF: Cognitive Level: Application REF: p. 42 OBJ: 11
TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Safe, Effective Care Environment
- Which is an example of an interdependent nursing action?
| a. | Assess lung sounds every 4 hours. |
| b. | Educate the patient about the prescribed medication. |
| c. | Administer Demerol 50 mg intramuscularly (IM) every 4 hours PRN. |
| d. | Encourage the patient to express feelings. |
ANS: C
“Administer Demerol 50 mg IM every 4 hours PRN” requires the nurse to follow the parameters of the order, yet use nursing judgment to determine how often the medication is to be administered; therefore, it is an interdependent nursing action. Assessing lung sounds, educating the patient about medication, and encouraging the patient to express feelings are independent nursing actions.
DIF: Cognitive Level: Application REF: p. 45 OBJ: 12
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe, Effective Care Environment
- What is the nurse’s primary source of information when obtaining a patient history?
| a. | The physician |
| b. | The patient record |
| c. | The family |
| d. | The patient |
ANS: D
The focus of the nursing process is the patient. Although family members contribute to the nursing history, this information is secondhand. It is important that the nurse continue to assess patient data for validation of this information. The physician is not to be relied on to provide information about a complete patient history. The patient record reflects only recorded past information and not current input that may be relevant. The family may provide information about a patient history if the patient is unable to provide it, but the information is subject to interpretation by someone other than the patient.
DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 13
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Safe, Effective Care Environment
- An obese patient did not meet the goal of “by the end of the second week, is able to follow a 1500 calorie diet.” What will the nurse and the patient reassess?
| a. | Patient’s weight |
| b. | Patient’s understanding of the 1500 calorie diet |
| c. | Nurse’s feelings about obese patients |
| d. | Health care agency’s ability to provide the prescribed diet |
ANS: B
When goals are not met, the nurse must reassess the patient’s understanding of the interventions and commitment to reaching the identified goal. All phases of the nursing process are ongoing as the nurse continues to evaluate, assess, and readjust interventions as indicated to facilitate patient achievement of outcomes. The patient may have followed the diet but not lost any weight. The nurse’s feelings should not be a factor in the assessment. The agency’s ability to provide the prescribed diet should have been determined before implementation of the plan.
DIF: Cognitive Level: Analysis REF: pp. 42-43 OBJ: 12
TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Safe, Effective Care Environment
- What is the priority nursing diagnosis for an older adult with diabetes who is hospitalized for pneumonia?
| a. | Deficient knowledge related to lack of information about diabetic medication |
| b. | Risk for falls related to weakness |
| c. | Impaired gas exchange related to decreased pulmonary ventilation |
| d. | Imbalanced nutrition: more than body requirements related to obesity |
ANS: C
Airway is the first priority in a needs assessment (ABCs = airway, breathing, circulation). Medication, weakness, and nutrition are less of a priority than the patient’s respiratory status.
DIF: Cognitive Level: Analysis REF: pp. 37-38 OBJ: 9
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- What is a critical care pathway?
| a. | A nursing care plan for a patient in a critical care unit |
| b. | A standardized care plan derived from best practice patterns |
| c. | A care plan that has been critiqued by a quality improvement officer |
| d. | A care plan based on measurable goals and outcomes |
ANS: B
A critical care pathway is a standardized care plan derived from best practice patterns, enabling the nurse to develop a treatment plan that sequences detailed clinical interventions to be performed over a projected amount of time for a specific case type of disease process. A nursing care plan for a patient in a critical care unit is not a critical care pathway. A care plan that has been critiqued by a quality improvement officer is not a critical care pathway. All good care plans are based on measurable goals and outcomes.
DIF: Cognitive Level: Knowledge REF: p. 40 OBJ: 7
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity
- When a nursing diagnosis statement is written, who or what directs the nurse to identify appropriate nursing interventions?
| a. | Other nurses on staff who have experience with the diagnoses |
| b. | The patient and family who have an interest in the outcome |
| c. | The etiologies of the problems identified in the nursing diagnoses |
| d. | The medical staff who have more expertise than the nurses |
ANS: C
Nursing actions are suggested by the etiologies of the problems identified in the nursing diagnoses and are used to implement plans. Nursing actions are not suggested by other nurses, the patient and family, or by the medical staff.
DIF: Cognitive Level: Comprehension REF: p. 42 OBJ: 12
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity
- A patient is experiencing adverse effects of a medication. Which information obtained by the nurse is subjective?
| a. | Cough |
| b. | Edema |
| c. | Nausea |
| d. | Tachycardia |
ANS: C
Nausea is a symptom for which only the person experiencing it can provide the information. Cough is heard by the nurse. Edema is measured and seen by the nurse. Tachycardia is assessed by the nurse.
DIF: Cognitive Level: Application REF: p. 43 OBJ: 13
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse has determined that the pain medication given to a patient an hour ago has been effective. The nurse is using which step of the nursing process?
| a. | Evaluation |
| b. | Intervention |
| c. | Nursing diagnosis |
| d. | Planning |
ANS: A
The nurse has used evaluation to assess the response to the administered medication. Intervention is the administration of the medication or teaching about the medication in this situation. This situation is not an example of making a nursing diagnosis. Planning is developing goal statements and prioritizing patient problems.
DIF: Cognitive Level: Application REF: pp. 42-43 OBJ: 15
TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity
- Prior to the administration of a nephrotoxic drug, the nurse determines that the kidney lab data are within normal range. Which step of the nursing process is being used?
| a. | Assessment |
| b. | Nursing diagnosis |
| c. | Planning |
| d. | Evaluation |
ANS: A
The nurse is collecting information about renal function through lab data; this is baseline assessment data. This action is not an example of the development of a nursing diagnosis. Planning is developing goal statements and prioritizing patient problems. Evaluation determines if goals have been met.
DIF: Cognitive Level: Application REF: p. 36 OBJ: 2
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- Which statement best describes the planning phase of the nursing process?
| a. | Administer insulin subcutaneously (subcut) in the abdominal area. |
| b. | Patient is at high risk for falls related to hypotension. |
| c. | The patient will state the expected adverse effects of medication by the end of the teaching session. |
| d. | Itching has resolved; medication given is effective. |
ANS: C
“The patient will state the expected adverse effects of medication by the end of the teaching session” is an example of a goal statement that is developed in the planning phase. Administration of insulin subcut is an example of the implementation phase. Noting a high risk for falls related to hypotension is an example of the second phase or nursing diagnosis. Stating that the medication given is effective is an example of the evaluation phase.
DIF: Cognitive Level: Application REF: p. 39 OBJ: 2 | 7
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse is prioritizing care of a pediatric patient diagnosed with cystic fibrosis. Which nursing diagnosis would the nurse consider the highest priority?
| a. | Risk for altered nutrition: less than body related to decreased appetite |
| b. | Altered breathing pattern related to thickened mucus secretions |
| c. | Knowledge deficit related to disease process |
| d. | Impaired skin integrity related to decreased mobility |
ANS: B
Altered breathing pattern would be the highest priority because the physiologic need of oxygenation is required for total body function. Risk for altered nutrition, knowledge deficit, and impaired skin integrity would not be of higher priority than oxygenation.
DIF: Cognitive Level: Analysis REF: p. 40 OBJ: 9
TOP: Nursing Process Step: Diagnosis
MSC: NCLEX Client Needs Category: Physiological Integrity
MULTIPLE RESPONSE
- Which statement(s) regarding critical pathways is/are true? (Select all that apply.)
| a. | Efficient for specific diseases or case types |
| b. | The same as medical plans |
| c. | Standardized and enhanced quality care |
| d. | Evaluated less frequently than care plans |
| e. | Enhanced communication for a variety of health care providers |
ANS: A, C, E
Critical pathways are standardized care plans that detail clinical interventions to be performed over a projected time frame for a specific disease or case type. Physician interventions are included in the pathways. Critical pathways enhance the quality of care and require evaluation and modification on an ongoing basis. Critical pathways assist as a communication system for all health care providers. Medical plans are distinct to physicians. Critical pathways should be evaluated as needed to achieve desired outcomes.
DIF: Cognitive Level: Comprehension REF: p. 40 OBJ: 7 | 8
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Safe, Effective Care Environment
- In which way(s) is nursing diagnosis different from a medical diagnosis? (Select all that apply.)
| a. | Statement of the patient’s alterations in structure and functions |
| b. | Description of the patient’s ability to function in relation to impairment |
| c. | Tend to remain the same throughout the course of illness or recovery from injury |
| d. | Varies depending on patient’s state of recovery |
| e. | Based on research done by nurses |
| f. | Conditions can be accurately identified by nursing assessment methods |
ANS: B, D, E, F
Nursing diagnoses, as exemplified by the NANDA I taxonomy, are statements about the patient’s ability to function in relation to an illness or injury, vary with the patient’s state of recovery, are based on research done by nurses, and can be determined based on nursing assessment methods. Nursing diagnoses do not include statements of the patient’s alterations in structure and function and do not remain the same throughout the course of illness or recovery from injury.
DIF: Cognitive Level: Comprehension REF: pp. 37-38 OBJ: 6
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse is participating in the planning phase of the nursing process for a new admission to a long term care facility. When formulating a plan to meet the patient’s needs, the nurse will take which action(s)? (Select all that apply.)
| a. | Formulate nursing interventions. |
| b. | Collect data. |
| c. | Make a clinical judgment about the patient. |
| d. | Set priorities. |
| e. | Develop measurable goals. |
ANS: A, D, E
Planning is the third phase of the five step nursing process. Once the patient has been assessed and problems have been diagnosed, plans should be formulated to meet the patient’s needs. Planning usually encompasses four phases: (1) priority setting, (2) development of measurable goal and outcome statements, (3) formulation of nursing interventions, and (4) formulation of anticipated therapeutic outcomes that can be used to evaluate the patient’s status. Collecting data is part of the assessment phase of the nursing process. Making a clinical judgment about the patient takes place during the diagnosis phase.
DIF: Cognitive Level: Application REF: p. 39 OBJ: 7 | 8
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity
- The nurse is preparing a patient’s prescribed medications. In order to ensure patient safety, the nurse will perform which intervention(s)? (Select all that apply.)
| a. | Select the correct supplies. |
| b. | Administer the medication by the correct route. |
| c. | Use room number to identify correct patient. |
| d. | Educate patient regarding medications prescribed. |
| e. | Document in chart all aspects of medication administration. |
ANS: A, B, D, E
The nurse prepares prescribed medications using procedures to ensure patient safety, including selecting correct supplies, administering medication by the correct route, educating patients regarding medications prescribed, and documenting in chart all aspects of medication administration. To improve the accuracy of patient identification, it is now recommended that two patient identifiers, neither of which is the room number, be used when administering medications. Best practice would be to look at the patient’s name band for identity and to request that the patient state his or her name and birth date.
DIF: Cognitive Level: Application REF: p. 45 OBJ: 13 | 14
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe, Effective Care Environment
OTHER
- Rank the patient needs according to Maslow’s hierarchy, beginning with the lowest level need to the highest level need. (Enter your answer with a comma and space between each lettered option as follows: A, B, C, D, E.)
- A patient would like to write a book.
- A patient becomes frightened when no one answers the call light during the night.
- A pediatric patient is worrying that school friends will forget him.
- A patient needs to be repositioned in bed.
- A chronically ill patient states that he feels worthless because he is unable to support his family.
ANS:
D, B, C, E, A
The needs should be addressed in the following order: The patient’s need for repositioning represents a basic need for comfort; the patient’s alarm when the call light is not answered represents fear for safety; the patient’s worry about his school friends forgetting him represents a threat to sense of love and belonging; the patient’s feeling of worthlessness represents threatened self esteem; and the patient’s desire to write a book is related to self actualization.
DIF: Cognitive Level: Analysis REF: p. 40 OBJ: 9
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Health Promotion and Maintenance
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