Chapter 01: The Nursing Process and Drug Therapy

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

Chapter 01: The Nursing Process and Drug Therapy 5

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?

Chapter 01: The Nursing Process and Drug Therapy 6

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

Chapter 01: The Nursing Process and Drug Therapy 7

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

c. Right dose

d. Right diagnosis

e. Right time

f. Right patient

ANS: A, B, C, E, F

Additional rights of medication administration must always include the right drug, right dose,

right time, right route, and right patient. The right diagnosis is incorrect.

DIF: COGNITIVE LEVEL: Remembering (Knowledge) REF: p. 9

TOP: NURSING PROCESS: Implementation

MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control

2. Place the phases of the nursing process in the correct order, with 1 as the first phase and 5 as the

last phase. (Select all that apply.)

a. Planning

b. Evaluation

c. Assessment

d. Implementation

e. Nursing Diagnoses

ANS: A, B, C, D, E

The nursing process is an ongoing process that begins with assessing and continues with

diagnosing, planning, implementing, and evaluating.

DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 4

TOP: NURSING PROCESS: General

MSC: NCLEX: Safe and Effective Care Environment: Management of Care

Chapter 02: Pharmacologic Principles 8

Chapter 02: Pharmacologic Principles

MULTIPLE CHOICE

1. The patient is receiving two different drugs. At current dosages and dosage forms, both drugs are

absorbed into the circulation in identical amounts. Which term is used to identify this principle?

a. Bioequivalent

b. Synergistic

c. Prodrugs

d. Steady state

ANS: A

Two drugs absorbed into the circulation in the same amount (in specific dosage forms) have the

same bioavailability; thus, they are bioequivalent. A drug’s steady state is the physiologic state in

which the amount of drug removed via elimination is equal to the amount of drug absorbed from

each dose. The term synergistic refers to two drugs, given together, with a resulting effect that is

greater than the sum of the effects of each drug given alone. A prodrug is an inactive drug

dosage form that is converted to an active metabolite by various biochemical reactions once it is

inside the body.

DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 21

TOP: NURSING PROCESS: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

2. When given an intravenous medication, the patient says to the nurse, “I usually take pills. Why

does this medication have to be given in the arm?” What is the nurse’s best answer?

a. “The medication will cause fewer adverse effects when given intravenously.”

b. “The intravenous medication will have delayed absorption into the body’s tissues.”

c. “The action of the medication will begin sooner when given intravenously.”

d. “There is a lower chance of allergic reactions when drugs are given intravenously.”

ANS: C

An intravenous (IV) injection provides the fastest route of absorption. The IV route does not

affect the number of adverse effects, nor does it cause delayed tissue absorption (it results in

faster absorption). The IV route does not affect the number of allergic reactions.

DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 22

TOP: NURSING PROCESS: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

3. The nurse is administering parenteral drugs. Which statement is true regarding parenteral drugs?

a. Parenteral drugs bypass the first-pass effect.

b. Absorption of parenteral drugs is affected by reduced blood flow to the stomach.

c. Absorption of parenteral drugs is faster when the stomach is empty.

d. Parenteral drugs exert their effects while circulating in the bloodstream.

ANS: A

Chapter 02: Pharmacologic Principles 9

Drugs given by the parenteral route bypass the first-pass effect. Reduced blood flow to the

stomach and the presence of food in the stomach apply to enteral drugs (taken orally), not to

parenteral drugs. Parenteral drugs must be absorbed into cells and tissues from the circulation

before they can exert their effects; they do not exert their effects while circulating in the

bloodstream.

DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 22

TOP: NURSING PROCESS: General

MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

4. When monitoring the patient receiving an intravenous infusion to reduce blood pressure, the

nurse notes that the patient’s blood pressure is extremely low, and the patient is lethargic and

difficult to awaken. This would be classified as which type of adverse drug reaction?

a. Adverse effect

b. Allergic reaction

c. Idiosyncratic reaction

d. Pharmacologic reaction

ANS: D

A pharmacologic reaction is an extension of a drug’s normal effects in the body. In this case, the

antihypertensive drug lowered the patient’s blood pressure levels too much. The other options do

not describe a pharmacologic reaction. An adverse effect is a predictable, well-known adverse

drug reaction that results in minor or no changes in patient management. An allergic reaction

(also known as a hypersensitivity reaction) involves the patient’s immune system. An

idiosyncratic reaction is unexpected and is defined as a genetically determined abnormal

response to normal dosages of a drug.

DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 32

TOP: NURSING PROCESS: General

MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

5. The nurse is reviewing pharmacology terms for a group of newly graduated nurses. Which

sentence defines a drug’s half-life?

a. The time it takes for the drug to cause half of its therapeutic response

b. The time it takes for one half of the original amount of a drug to reach the target

cells

c. The time it takes for one half of the original amount of a drug to be removed from

the body

d. The time it takes for one half of the original amount of a drug to be absorbed into

the circulation

ANS: C

A drug’s half-life is the time it takes for one half of the original amount of a drug to be removed

from the body. It is a measure of the rate at which drugs are removed from the body. The other

options are incorrect definitions of half-life.

DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 27

TOP: NURSING PROCESS: General

MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies