Pharmacology and the Nursing Process 6th Edition By Lilley-Test Bank

Chapter 01: Drug Therapy and the Nursing Process

MULTIPLE CHOICE

1. In developing a nursing diagnosis for a patient recently diagnosed with type 2 diabetes, which response represents the proper format for a nursing diagnosis?
A. Nervousness
B. Nervousness related to new medication
C. Nervousness related to feelings about medication as shown by statements like “I’m upset about having to inject myself”
D. Nervousness related to new medication as evident from statements like “I’m upset about having to inject myself”

ANS: D
Creating nursing diagnoses typically involves a three-step process. “Nervousness” lacks the “related to” and “as evident by” sections. “Nervousness related to new medication” lacks the “as evident by” section of defining characteristics. The statement starting with “Nervousness related to anxious feelings” is incorrect since the “related to” section is just a repetition of the problem “nervousness,” not a distinct factor connected to the response.

DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: Page 9
TOP: NURSING PROCESS: Nursing Diagnosis
MSC: NCLEX: Safe and Effective Care Environment: Management of Care

2. A patient is prescribed oral digoxin (Lanoxin) daily, but due to difficulty swallowing, they are unable to take it orally as instructed. What kind of issue does this represent?
A. “Right time” issue
B. “Right dose” issue
C. “Right route” issue
D. “Right medication” issue

ANS: C
Since the patient cannot swallow, the prescriber must modify the prescribed route. “Time” is not accurate as the appointed frequency has not been altered. “Dose” is incorrect as the dose is not affected by inability to swallow. “Medication” is incorrect as the medication ordered remains the same, only the route changes.

DIF: COGNITIVE LEVEL: Applying (Application) REF: Page 13
TOP: NURSING PROCESS: Implementation
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
3. Monitoring a patient’s progress on a new drug regimen since the initial dose and documenting signs of potential adverse effects illustrates which phase of the nursing process?
A. Planning
B. Evaluation
C. Implementation
D. Nursing diagnosis

ANS: B
Tracking the patient’s progress is part of the evaluation phase. Planning, Implementation, and Nursing Diagnosis are not exemplified by this scenario.

DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: Page 14
TOP: NURSING PROCESS: Evaluation
MSC: NCLEX: Safe and Effective Care Environment: Management of Care

4. When caring for a patient newly diagnosed with type 1 diabetes mellitus, which response best demonstrates an outcome criterion for this patient?
A. The patient will adhere to the new insulin treatment regimen.
B. The patient will follow instructions.
C. The patient will not experience complications.
D. The patient will exhibit safe insulin self-administration technique.

ANS: D
“Exhibiting safe insulin self-administration technique” is a specific and measurable outcome criterion. “Following instructions” and “not experiencing complications” are not specific criteria. “Adhering to new regimen” would be hard to measure.

DIF: COGNITIVE LEVEL: Applying (Application) REF: Page 10
TOP: NURSING PROCESS: Planning
MSC: NCLEX: Safe and Effective Care Environment: Management of Care

5. What action best represents the implementation phase of the nursing process for a patient newly diagnosed with type 1 diabetes mellitus?
A. Offering guidance on self-injection technique
B. Establishing goals and outcome criteria with patient input
C. Documenting a drug history related to over-the-counter medications used at home
D. Formulating nursing diagnoses linked to knowledge deficit about new treatment regimen

ANS: A
Education is an intervention occurring during the implementation phase. Setting goals and outcomes reflects the Planning phase. Documenting a drug history reflects the Assessment phase. Formulating nursing diagnoses demonstrates data analysis as part of Planning.

DIF: COGNITIVE LEVEL: Applying (Application) REF: Pages 10-11
TOP: NURSING PROCESS: Implementation
MSC: NCLEX: Safe and Effective Care Environment: Management of Care

6. The medication order requests, “Give ondansetron 24 mg, 30 minutes before starting chemotherapy to prevent nausea.” The nurse notices that the route is absent from the order. What is the nurse’s best course of action?
A. Administering the medication intravenously as it is for nausea prevention
B. Administering the medication orally as the tablets are obtainable in 24 mg doses
C. Contacting the prescriber to clarify the route of the medication ordered
D. Withholding the medication until the prescriber clarifies the order

ANS: C
A comprehensive medication order includes the route of administration. If a medication order lacks the route, the nurse must request the prescriber to clarify. The other choices are not correct actions.

DIF: COGNITIVE LEVEL: Applying (Application) REF: Page 13
TOP: NURSING PROCESS: Implementation
MSC: NCLEX: Safe and Effective Care Environment: Management of Care

7. When considering the timing of a drug dose, which of the following factors is appropriate to think about when determining when to administer a drug?
A. The patient’s ability to swallow
B. The patient’s weight
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 impacted by the timing of the last meal. The patient’s ability to swallow, weight, and allergies are not factors to consider regarding the timing of the drug’s administration.

DIF: COGNITIVE LEVEL: Applying (Application) REF: Page 13
TOP: NURSING PROCESS: Assessment
MSC: NCLEX: Safe and Effective Care Environment: Management of Care

MULTIPLE RESPONSE

1. When administering medications, the nurse must follow the rights of medication administration, which include what rights? Select all that apply.
A. Right drug
B. Right route
C. Right dose
D. Right time
E. Right patient
F. Right documentation

ANS: A, B, C, D, E, F
The Six Rights of Medication Administration must include the right drug, the right route, the right dose, the right time, the right patient, and the right documentation.

DIF: COGNITIVE LEVEL: Remembering (Knowledge) REF: Page 11
TOP: NURSING PROCESS: Implementation
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control

OTHER

1. Arrange the phases of the nursing process in the correct sequence, with 1 as the initial phase and 5 as the final phase.
1. Assessment
2. Nursing Diagnoses
3. Planning
4. Implementation
5. Evaluation

ANS:
1, 2, 3, 4, 5
The nursing process is a continuous process that starts with assessing and progresses through diagnosing, planning, implementing, and evaluating.

DIF: COGNITIVE LEVEL: Applying (Application) REF: Page 6
TOP: NURSING PROCESS: General
MSC: NCLEX: Safe and Effective Care Environment: Management of Care