Davis Advantage for Medical-
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• PublisherPublished by F.A.
Davis Copyright© 2024
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Clinical Scenario:
A postoperative patient who received IV morphine 20 minutes
ago is difficult to arouse. The respiratory rate is 8/min, oxygen
saturation is 88% on room air, and the skin is cool and clammy.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage the patient to take deep breaths and cough
B. Stop the opioid infusion if running and support
airway/breathing
C. Notify the provider after rechecking vital signs in 30 minutes
D. Document the findings as an expected opioid effect
Correct Answer:
B
Detailed Rationale:
The patient shows respiratory depression, a life-threatening
opioid adverse effect. The nurse must act immediately to
protect airway and breathing, stop the opioid source if
applicable, and provide oxygen/support per protocol. This
reflects the priority principle of ABCs and rapid intervention for
deterioration.
Incorrect Option Analysis:
, • A: Deep breathing alone is insufficient for a patient with
depressed respirations. Misconception: mild sedation can
be treated with coaching only. Risk: delayed treatment of
hypoventilation and hypoxemia.
• C: Waiting 30 minutes is unsafe. Misconception: trends
can be monitored before acting. Risk: respiratory arrest.
• D: This is not expected or benign. Misconception: opioids
always just “make patients sleepy.” Risk: missing a critical
adverse event.
Nursing Process Linkage:
Implementation
NCJMM Competencies:
Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty Level:
Difficult
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Recognize and respond to opioid-induced respiratory
depression using priority nursing actions.
2) MCQ
, Clinical Scenario:
An older adult is admitted for gastrointestinal bleeding. The
patient says, “My daughter should be included in every
discussion because she helps me make decisions, but I want to
answer for myself.”
Question Stem:
Which nursing response best demonstrates patient-centered
care?
Answer Options:
A. “I will speak directly to your daughter since she helps with
decisions.”
B. “I will ask you what information you want shared and who
you want involved.”
C. “I will give the same discharge teaching I use for all patients.”
D. “I will wait until your daughter arrives before I start the
assessment.”
Correct Answer:
B
Detailed Rationale:
Patient-centered care means respecting the patient’s values,
preferences, and autonomy while involving family or caregivers
as desired by the patient. The nurse should ask about
preferences, consent for sharing information, and desired
participation in care.
Incorrect Option Analysis:
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• PublisherPublished by F.A.
Davis Copyright© 2024
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Clinical Scenario:
A postoperative patient who received IV morphine 20 minutes
ago is difficult to arouse. The respiratory rate is 8/min, oxygen
saturation is 88% on room air, and the skin is cool and clammy.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage the patient to take deep breaths and cough
B. Stop the opioid infusion if running and support
airway/breathing
C. Notify the provider after rechecking vital signs in 30 minutes
D. Document the findings as an expected opioid effect
Correct Answer:
B
Detailed Rationale:
The patient shows respiratory depression, a life-threatening
opioid adverse effect. The nurse must act immediately to
protect airway and breathing, stop the opioid source if
applicable, and provide oxygen/support per protocol. This
reflects the priority principle of ABCs and rapid intervention for
deterioration.
Incorrect Option Analysis:
, • A: Deep breathing alone is insufficient for a patient with
depressed respirations. Misconception: mild sedation can
be treated with coaching only. Risk: delayed treatment of
hypoventilation and hypoxemia.
• C: Waiting 30 minutes is unsafe. Misconception: trends
can be monitored before acting. Risk: respiratory arrest.
• D: This is not expected or benign. Misconception: opioids
always just “make patients sleepy.” Risk: missing a critical
adverse event.
Nursing Process Linkage:
Implementation
NCJMM Competencies:
Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty Level:
Difficult
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Recognize and respond to opioid-induced respiratory
depression using priority nursing actions.
2) MCQ
, Clinical Scenario:
An older adult is admitted for gastrointestinal bleeding. The
patient says, “My daughter should be included in every
discussion because she helps me make decisions, but I want to
answer for myself.”
Question Stem:
Which nursing response best demonstrates patient-centered
care?
Answer Options:
A. “I will speak directly to your daughter since she helps with
decisions.”
B. “I will ask you what information you want shared and who
you want involved.”
C. “I will give the same discharge teaching I use for all patients.”
D. “I will wait until your daughter arrives before I start the
assessment.”
Correct Answer:
B
Detailed Rationale:
Patient-centered care means respecting the patient’s values,
preferences, and autonomy while involving family or caregivers
as desired by the patient. The nurse should ask about
preferences, consent for sharing information, and desired
participation in care.
Incorrect Option Analysis:
