CH 4 NURSING PROCESS

Question 1

1. A 70-year-old patient has just received a drug that can cause sedation. What would be the priority nursing diagnosis for this patient?

A) Noncompliance: Cost of the drug
B) Deficient knowledge: Unfamiliar with drug therapy
C) Risk for injury: Related to adverse effects of the drug
D) Ineffective health maintenance: Need for medication

Answer 1

Ans: C
Feedback:
Because of the patient’s age and that the medication causes sedation, the highest priority nursing diagnosis is related to maintaining the patient’s safety. Safety for the patient is the nurse’s number one concern. There is nothing indicated related to the cost of the drug or the risk of noncompliance for this patient. Deficient knowledge will need to be addressed but it is not the priority when compared with patient safety. There is no indication the patient’s need for this medication is related to an ineffective health maintenance issue.

Question 2

2. What is the responsibility of the nurse related to the patient’s drug therapy? (Select all that apply.)

A) Teaching the patient how to cope with therapy to ensure the best outcome B) Providing therapy as well as medications
C) Evaluating the effectiveness of therapy
D) Altering the drug regimen to optimize outcome
E) Recommending appropriate over-the-counter medications to treat adverse effects of prescription drug therapy

Answer 2

Ans: A,B,C
Feedback:
A nurse is, therefore, a key health care provider who is in a position to assess the whole patient, to administer therapy as well as medications, to teach the patient how best to cope with the therapy to ensure the most favorable outcome, and to evaluate the effectiveness of the therapy. Nurses do not alter drug therapy or recommend over-the-counter medications because prescribing is outside the nurse’s scope of practice.

Question 3

3. The nurse is gathering assessment data from a medication history of a 38-year-old man with four children. What assessment information would be most important in providing care for this patient?

A) The medication history of the patient’s mother and/or father
B) The name of the patient’s pharmacy
C) Insurance, financial support, and stability for the patient and his family
D) The last time the patient was hospitalized

Answer 3

Ans: C
Feedback:
In this situation, insurance, financial support, and stability would be the most important data and may determine compliance with future drug therapy. The medication history of the patient’s parents could indicate a pattern of overall attitude about drug therapy but is not the priority concern. The last time the patient was hospitalized could indicate whether the patient seeks medical care when appropriate or if he self-medicates, contributing to the nurse’s knowledge of this individual but this is not the priority concern. The name of the pharmacy would be unnecessary unless the nurse anticipates having to call a prescription in to the pharmacy for the prescriber.

Question 4

4. During what phase of the nursing process would the nurse be required to consider the efficacy of nursing interventions related to drug therapy?

A) Assessment
B) Nursing diagnosis
C) Interventions
D) Evaluation

Answer 4

Ans: D
Feedback:
Evaluation allows the nurse to review what has changed since intervening to determine whether the nursing care has had a positive, therapeutic effect moving the patient toward a more healthful life. If outcomes have not improved, the nurse begins again at the assessment phase of the nursing process with the goal of changing the plan of care to improve outcomes. The patient’s response to the drug and occurrence of adverse drug effects indicate the effectiveness of the nursing interventions related to drug therapy. Assessment involves a systematic, organized collection of data concerning a patient. A nursing diagnosis indicates actual or potential alterations in patient function based on the assessment of the clinical situation. Interventions are actions taken to meet the patient’s needs, such as administration of drugs.

Question 5

5. When the nurse reads in the drug handbook the section related to recommended dosage, it is important to remember that this suggested dosage is based on what?

A) A 40-year-old man
B) An average-sized adult
C) A 150-pound adult male
D) A healthy young adult

Answer 5

Ans: C
Feedback:
Drug studies base the therapeutic dosage, or that dose needed to reach a critical concentration, on the physiology of a 150-pound healthy adult male. Testing is not routinely done in women because of the potential for unknown effects on the ova. Testing would not be done on an obese adult or older adult because of the potential for underlying disease, altered metabolism, or reactions to the drug. Children and adolescents are never used for testing due to ethical concerns.

Question 6

6. A nurse is caring for a child on the pediatric unit. A drug is ordered for the child, but no pediatric dose is listed for the drug. To make sure that the right dose has been ordered, what will the nurse use to calculate the correct dose?

A) Surface area
B) Height
C) Birth date
D) Adult dosage

Answer 6

Ans: A
Feedback:
The surface area of a child is calculated using height and weight. It is the most accurate way to determine an appropriate dosage for that child. Age does not take into consideration variations in growth. Height alone does not take into account the mass of the child. Gestational age is simply a distracter.

Question 7

7. You are evaluating the discharge teaching you have done with your patient concerning drug therapy. What statement from the patient would indicate that teaching had been effective?

A) “I have to take three pills each day and I can take them at the time that fits my
schedule.”
B) “I should take the white pill in the morning because the doctor wants me to take
it.”
C) “I will add the names and dosages of these new drugs to my medication list in my
wallet.”
D) “I have prescriptions at different pharmacies. I shop around for the best price for
each drug.”

Answer 7

Ans: C
Feedback:
The patient needs to recognize the importance of keeping an updated list of all current medications and the need to share this list with all health care providers to avoid drug-drug interactions. The patient should understand exactly when to take medications, why that medication is being taken, and how to take it safely. Patients should be encouraged to use a single pharmacy because this will add another layer of safety because the pharmacy will know all drugs being prescribed to this patient.

Question 8

8. The nurse would expect to see an adjusted dosage in what patients? (Select all that apply.)

A) Young adult women 
B) Middle-aged men 
C) Infants
D) Neonates
E) Older adults

Answer 8

Ans: C, D, E
Feedback:
Patients at the extremes of the age spectrum—children and older adults—often require dosage adjustments based on the functional level of the liver and kidneys and the responsiveness of other organs. The child’s age and developmental level will also alert the nurse to possible problems with drug delivery, such as an inability to swallow pills or follow directions related to other delivery methods. The adult, whether male or female, would not require altered dosage unless a secondary condition such as renal or hepatic alterations existed.

Question 9

9. When taking a medication history on a patient why should the nurse ask about the use of complementary or alternative therapies?

A) Patients starting on new drugs are usually not compliant with medical regimens.
B) Many drug-alternative therapy interactions can cause serious problems.
C) Natural products may be more effective and the prescribed drug may not be needed.
D) The cost of the drug and the alternative therapy may be too expensive for the patient to handle.

Answer 9

Ans: B
Feedback:
Alternative therapies often involve the use of herbal products, which contain natural chemicals that affect the body. Many drug-alternative therapy interactions have been reported that could cause serious adverse effects, but patients often don’t think to mention these therapies when asked about the medications they are taking. The health care provider needs to be alert to these possible interactions and to adjust treatment appropriately. Cost and effectiveness may be factors, but the balancing of these therapies in the drug regimen to prevent interactions is the main concern of the nurse.

Question 10

10. The nurse is reviewing the patient’s medication orders and finds an order stating “amoxicillin 250 mg every 8 hours.” What would the nurse question regarding this order?

A) Dose
B) Route
C) Frequency of administration
D) Allowance for generic substitution

Answer 10

Ans: B
Feedback:
For the nurse to administer a medication, all essential components of a medication order must be written by the prescriber including drug name, dosage, route, frequency, and patient name. This order is missing the route and the drug could be given IV, IM, or PO. The nurse should call the ordering health care provider and clarify what route the medication is to be administered.

Question 11

11. The home health nurse is caring for a 77-year-old patient with congestive heart failure. What would the nurse consider a priority to assess to develop the most effective plan of care related to medication administration?

A) Description of the patient’s living environment
B) Required lifestyle changes
C) Family members in the community
D) Compliance with therapy to reduce risk of skin breakdown

Answer 11

Ans: B
Feedback:
Nurses must consider how a person responds to disease and its treatment, including the changes in lifestyle that may be required. By recognizing required lifestyles during the home visit the nurse can teach the patient how to make healthy choices and support the process of changing to new choices. Although the environment would impact the physical plan of care, it would not be a factor in the administration of medications. Assessment of family members in the community would not be a necessary part of the assessment in relation to the patient’s drug therapy. Nothing suggests the patient is at risk for skin breakdown so this would not factor into the medication regimen.

Question 12

12. Student nurses are learning to weigh patients and do vital signs. How does a correct weight impact administering medication?

A) Proper dosage calculation
B) Assessing changes in fluid balance
C) Assessing changes in nutritional status
D) Caloric needs

Answer 12

Ans: A
Feedback:
Dosage of medication is often calculated based on the patient’s weight, so getting patients’ weight wrong could cause a medication error. The patient’s weight gives information into fluid balance, nutritional status, and caloric needs but this is not associated with drug therapy. However, a patient’s weight is most important in determining the appropriateness of drug dosage.

Question 13

13. Teaching the patient/caregiver about her or his medications is an important step in reducing the risk of medication errors. What is an important teaching point about medications? (Select all that apply.)

A) Speak up and ask questions.
B) Store medications in a warm humid place.
C) Adjust your medication according to how you feel.
D) Keep a list of your prescribed medications.
E) Take all medications together in the morning.

Answer 13

Ans: A,D
Feedback:
Appropriate patient teaching will reduce the risk of medication errors and complications. Nurses teach patients to speak up, ask questions, and act as his or her own advocate when medications are being prescribed. He should keep a complete list of medications and have a copy available at all times in case of accident. Store drugs in a dry, cool place away from children and pets that could be harmed. Take medications as they have been prescribed and do not adjust dosage without authorization from the prescriber. Take medications at the time they are prescribed to be taken, always being aware that some drugs cannot be taken together.

Question 14

14. A 73-year-old male patient is being discharged home today. The discharge order reads: Take 10 mL of guaifenesin (Robitussin) PO q4h. This over-the-counter pharmaceutical comes in bottles with plastic measuring caps. How much should the nurse teach the patient to take at home?

A) 1/2 tsp
B) 1 tsp
C) 2 tsp
D) 1 tbsp

Answer 14

Ans: C
Feedback:
The nurse is responsible for teaching the patient the correct drug dosage. You should teach the patient that 5 mL = 1 tsp, so 10 mL (5 × 2) = 2 tsp; therefore Options A, B, and D are incorrect. It is important that patients be taught how to take their medication using measurement systems they are familiar with and know how to use.

Question 15

15. It is important for the nurse to evaluate the efficacy of what parameter when evaluating the drug therapy of a patient?

A) Appropriateness of drug dosages
B) Compliance
C) Caregivers’ knowledge level
D) Nursing interventions

Answer 15

Ans: D
Feedback:
During the evaluation phase of care, nurses evaluate how effective care has been in meeting outcome goals. Appropriateness of drug dosages should be determined before administering the medication and not when evaluating their effects. Often, compliance cannot be evaluated until the nurse evaluates the effectiveness of therapy and finds the drug is not performing as expected, at which time the nurse may question the patient about whether medications are being taken as ordered. Caregivers’ knowledge level is an assessment providing data that will determine the teaching plan.

Question 16

16. The nurse is conducting an admission assessment on a patient. When collecting data related to medications the nurse asks “What medications are you currently taking?” After collecting this information, what other questions should the nurse ask? (Select all that apply.)

A) “Do you take any medications?”
B) “What over-the-counter (OTC) medications do you take?”
C) “Do you take an herbs, vitamins, or supplements?”
D) “Do you take medications safely when you take them?”
E) “Why do you take this medication?”

Answer 16

Ans: B,C
Feedback:
Patients often neglect to mention OTC drugs or alternative therapies (e.g., herbals) because they do not consider them to be actual drugs or they may be unwilling to admit their use to the health care provider. Ask patients specifically about OTC drug and alternative therapy use. The question “What medications are you taking?” has already been asked so there is no need to ask if they take any medications. Often, patients may take medications unsafely, so do not ask whether the patient takes drugs safely but instead assess exactly how they take medications to determine whether they are being taken safely. Patients should always know why they are taking each medication to understand whether they are getting the desired effect.

Question 17

17. A 27-year-old man is admitted to the emergency department (ED) after a serious motorcycle accident. The patient has a head injury, abrasions covering the left side of his body, a broken left femur, and internal injuries that are not fully assessed at this time. He is transferred from the ED to the intensive care unit (ICU). The nurse who is going to care for this patient in the ICU knows that a priority responsibility in regard to drug therapy is what?

A) Support vital functions
B) Continue curative treatment
C) Institute life-saving treatment
D) Monitor patient’s response

Answer 17

Ans: D
Feedback:
Because the nurse has the greatest direct and continued contact with the patient, the nurse is in the best position to detect minute changes that ultimately determine the course of drug therapy—therapeutic success or discontinuation because of adverse or unacceptable responses. The nurse would support vital functions, continue curative treatment, and institute life-saving treatment, but these actions occur regardless of drug therapy.

Question 18

18. When assessing a patient before starting a drug regimen, why would the nurse consider it important to assess baseline kidney function?

A) To anticipate adverse effects of drugs
B) To determine patient’s baseline electrolyte levels
C) To determine patient’s ability to excrete the drug
D) To determine patient’s ability to metabolize the drug

Answer 18

Ans: C
Feedback:
Patients with kidney or liver disease require very cautious medication administration, often needing dosages to be decreased and contraindicating some drugs altogether. The patient’s renal status will indicate the ability to excrete the drug. Liver function is needed to assess metabolism. Electrolyte levels would be indicated by serum blood test results, not by studies of kidney function. The nurse’s goal is to prevent or minimize adverse effects of drugs, not to anticipate them.

Question 19

19. A nurse is caring for a 77-year-old patient. The nurse plans care for this patient based on the knowledge that the aging process impacts drug therapy in what important way?

A) Blood volume decreases
B) Subcutaneous tissue increases
C) Total body water increases
D) Muscle mass increases

Answer 19

Ans: A
Feedback:
As patients age, the body undergoes many normal changes that can affect drug therapy, such as a decreased blood volume, decreased gastrointestinal (GI) absorption, reduced blood flow to muscles or skin, and changes in receptor site responsiveness. As a person ages, subcutaneous tissue decreases, total body water decreases, and muscle mass decreases.

Question 20

20. The nurse is caring for a patient who takes several drugs. What patient would the nurse monitor most closely because of an increased risk for adverse effects of medications?

A) The school-aged child
B) The obese middle-aged man
C) The adolescent
D) The newborn infant

Answer 20

Ans: D
Feedback:
Patients most likely to have adverse drug reactions include the very young or very old due to physiologic characteristics peculiar to these age groups. Therefore, the newborn infant would be at greater risk than the school-aged child who is at greater risk than the adolescent or middle-aged man.

Question 21

21. Which statement best describes drug efficacy/toxicity in pediatric patients?

A) Drug requirements for infants have been extensively studied.
B) Drug dosage is altered by age and weight in children.
C) Children always need smaller doses of medication than adults.
D) Infants and children are not at risk for drug toxicity if the dosage is correct.

Answer 21

Ans: B
Feedback:
All aspects of pediatric drug therapy must be guided by the child’s age, weight, and level of growth and development. Drugs are generally studied using healthy young men and are never studied in infants because they are not old enough to give consent for themselves. Drug dosages are very specific and a big child may weigh more than an adult and require a larger dose. Even when medications are given accurately, adverse effects can occur.

Question 22

22. A 7-year-old boy fell off a wood pile while playing. He has been admitted to the intensive care unit with multiple broken bones and internal bleeding. What should the nurse know about drug therapy in this type of patient?

A) Adverse effects may be decreased.
B) Therapeutic effects may be increased.
C) Pharmacodynamics may be altered.
D) Pharmacokinetics remain the same.

Answer 22

Ans: C
Feedback:
The child’s developmental age will influence pharmacokinetics and pharmacodynamics; the immature liver may not metabolize drugs in the same way and the kidneys may not work as efficiently as those of an adult. Adverse effects might be increased and therapeutic effects may be decreased.

Question 23

23. After admitting a patient to the unit, the nurse is organizing times to administer ordered medications. What important consideration will guide the nurse’s timing of each medication?

A) Comfort
B) Ethnicity of patient
C) Gender
D) Age

Answer 23

Ans: A
Feedback:
Organizing the day and the drug regimen to make it the least intrusive on a patient’s comfort can help to prevent errors and improve compliance. Ethnicity, gender, and age should be a consideration when ordering the drug, but after the drug is chosen it should be administered in a way that will maintain the patient’s quality-of-life.

Question 24

24. The nursing instructor is discussing drug therapy in the older adult. What would the instructor tell the students about what could affect therapeutic dosing in an older adult?

A) Changes in the gastrointestinal (GI) system can reduce drug absorption.
B) In older adults, drugs enter into circulation more quickly.
C) In older adults, drugs are distributed to a smaller portion of the tissues.
D) In older adults, drugs have an increased action.

Answer 24

Ans: A
Feedback:
As patients age, the body undergoes many normal changes that can affect drug therapy, such as a decreased blood volume, decreased GI absorption, reduced blood flow to muscles or skin, and changes in receptor site responsiveness. They are not released more quickly into circulation; distributed to a smaller portion of tissue; nor do they have an increased action.

Question 25

25. In today’s health care environment there is often more contact between the patient and the nurse than between the patient and the physician. How does this increased patient contact impact drug therapy?

A) Choosing the best medication to treat the patient’s condition
B) Assessing the patient’s preferred communication strategies
C) Assessing the therapeutic success of the drug therapy
D) Reducing dosage quickly when adverse effects arise

Answer 25

Ans: C
Feedback:
Because the nurse has the greatest direct and continued contact with the patient, the nurse is in the best position to detect minute changes that ultimately determine the course of drug therapy—therapeutic success or discontinuation because of adverse or unacceptable responses. The nurse does not choose the medication or reduce dosage because it is outside the scope of practice of the nurse. Communication strategies used by patients are not related to drug therapy.

Question 26

26. The nurse admits a patient to the unit and learns the patient has recently been diagnosed with chronic renal failure but has not informed the primary care provider of this diagnosis. What is the nurse’s first priority?
    A) Administer medications ordered immediately.
    B) Maintain the patient’s confidentiality.
    C) Call the admitting physician immediately.
    D) Provide teaching about chronic renal failure.

Answer 26

Ans: C
Feedback:
Knowledge of the patient’s diagnosed renal failure is essential to proper medication ordering because some dosages will need to be decreased whereas other medications may be contraindicated in this patient. The nurse does not breach confidentiality when sharing information that impacts needed care to the primary care provider. Teaching about renal failure may be provided at some point but it is not the priority in this situation. Medications should not be administered until they are appropriately adjusted by a health care provider who is aware of the renal failure diagnosis.

Question 27

27. It is often necessary to obtain baseline data prior to initiating many forms of drug therapy. These baseline data include what? (Select all that apply.)

A) Education level
B) Allergies
C) Drug use
D) Number of members in family
E) Father's occupation

Answer 27

Ans: A, B, C
Feedback:
Assessing educational level allows the nurse to plan an effective teaching plan. Allergies must be fully assessed before administering any medication to prevent allergic responses. Understanding the patient’s current drug use informs the nurse about drugs that may interact or be impacted. Knowing the number of family members and father’s occupation would not promote safer drug administration.

Question 28

28. A 32-year-old woman is admitted to the unit with a diagnosis of hypovolemia. The nurse is developing a care plan for this patient. What is an appropriate nursing diagnosis to help prevent medication errors?

A) Dysfunctional gastrointestinal motility
B) Ineffective self-health maintenance
C) Risk for injury
D) Deficient fluid volume

Answer 28

Ans: D
Feedback:
Hypovolemia is condition involving fluid volume in the body that is less than required. This would affect drug therapy for this patient and would be an important inclusion in the plan of care. The situation described does not indicate dysfunctional GI motility or ineffective self-health maintenance. A patient who is severely fluid volume deficient might be at risk for falls and injury but more information would be needed to make this determination.

Question 29

29. The nurse applies the nursing process in medication therapy to ensure what?

A) That medications are given at the right time
B) That care is efficient and effective
C) That the right dose of the drug is given to the patient
D) That the right drug is given to the right patient at the right time

Answer 29

Ans: B
Feedback:
Nurses use the nursing process as a decision-making, problem-solving process to improve the efficiency and effectiveness of care. Options A, C, and D are incorrect and do not describe why the nursing process is important as much as they explain how to give medications safely.

Question 30

30. A 35-year-old male patient is admitted to the hospital with pneumonia. He was originally being treated at home, but became worse when he quit taking his antibiotic prematurely. What is an appropriate nursing diagnosis for this patient?

A) Deficient knowledge: monitoring temperature
B) Noncompliance
C) Risk for injury related to hypoxia
D) Non-adherence: overuse

Answer 30

Ans: B
Feedback:
This patient did not take his antibiotic as directed. He quit taking his medication too soon, probably when he began to feel better so he was noncompliant with care. Why he quit taking the medication is unknown; it could have been a knowledge deficit or inability to pay for the full prescription. This will require further assessment to determine. Further data would need to be collected to determine whether the patient is experiencing hypoxia. He did not overuse his medication so option D is inaccurate.

Question 31

31. The nurse is reviewing the patient’s admission medication orders. What order would the nurse to question?

A) Digoxin .5 mg orally now–give one dose only
B) Lasix 20 mg. IV every 4 hours times 3
C) Gentamicin 80 mg IV to infuse over 1 hour every 12 hours
D) Acetaminophen 650 mg PO every 4 hours as needed for pain

Answer 31

Ans: A
Feedback:
The nurse should question the order for Digoxin.5 mg to make sure 0.5 mg is meant versus 5 mg, or what should have been ordered which is 0.05 mg. There should always be a 0 before a decimal point if no other number is present to make sure the decimal point is seen. The remaining orders could be administered as written.

Question 32

32. The nursing instructor observes several nursing students administer medications to their assigned patients. The instructor would stop what student from administering the medication until the error was corrected?

A) The student checks the label on the medication against the administration record
three times.
B) The student enters the patient’s room and asks the patient “Are you Mr. Jones?”
C) The student checks the drug’s brand name and generic name before taking it to the
patient.
D) The student documents the medication upon exiting the patient’s room.

Answer 32

Ans: B
Feedback:
When the student asks the patient, “Are you Mr. Jones” the patient may nod in agreement, even if that is not his name. Perhaps he misheard, or maybe he wasn’t paying attention to the name, or he may just want to be agreeable but this manner of ensuring the right patient receives a medication often results in errors. The student is correct to check the medication name against the medication administration record (MAR) three times to ensure the right drug is administered. The student who checks brand name and generic name is accurate in making sure the correct drug is prepared. Medication should be documented as soon as they are given so this student is also correct.

Question 33

33. The nurse is caring for a patient scheduled for surgery this morning who is not to be given anything orally. The nurse reviews the medication administration record and finds the patient has an important medication due but it is supposed to be given orally. What is the nurse’s best action?

A) Give the medication with a small sip of water.
B) Give the medication via a different route.
C) Hold the medication and put a note on the front of the chart for the surgeon.
D) Call the ordering health care provider and clarify administration.

Answer 33

Ans: D
Feedback:
The nurse would consult with the ordering provider to determine whether the medication should be held, given by another route, or taken with a sip of water. Administering the medication with a small sip of water could cause the cancellation of the procedure, either because of the sip of water or because the medication may interfere with anesthesia. The nurse cannot change the route of administration without an order. Holding the medication would constitute a drug error because the medication was not given on time.

Question 34

34. The nurse admits an older adult patient to the emergency room with reports of shortness of breath on exertion and a productive cough. The nurse reviews the patient’s current medications and the patient says, “I take one pink pill every morning.” The nurse asks the name of the drug and the patient says she doesn’t know. The patient cannot supply the name of the drug or the purpose in taking it either. This happens with four other medications the patient says she takes. What is an appropriate nursing diagnosis for this patient?

A) Acute confusion
B) Risk-prone health behavior
C) Ineffective health maintenance
D) Noncompliance

Answer 34

Ans: C
Feedback:
This patient is demonstrating ineffective health maintenance because knowledge of what medications are being taken and why they are being taken is essential to her health. Patients should be instructed to carry an up-to-date list of current medications to share with all health care providers. She is taking her medication as ordered according to what she said so that would eliminate risk-prone health behaviors and noncompliance. There is no indication the patient is confused.

Question 35

35. What action does the nurse take during the intervention state of the nursing process related to drug therapy? (Select all that apply.)

A) Administer the medication.
B) Determine medication effectiveness.
C) Document the medication. 
D) Analyze the data collected. 
E) Collect a nursing history.

Answer 35

Ans: A,C
Feedback:
During the implementation phase, the nurse administers and documents the medication. Effectiveness of the medication is determined during the evaluation phase. Analyzing data occurs when assigning appropriate nursing diagnoses. Collecting a nursing history is part of the assessment stage of the nursing process.