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
,Question 1 — MCQ
1. Question Number and Type
Q1 — MCQ
2. Clinical Scenario
A new graduate nurse is caring for a patient admitted with
pneumonia. During report, the nurse notes that the patient has
an oxygen saturation of 90% on room air, a respiratory rate of
24/min, and is speaking in full sentences.
3. Question Stem
Which action best reflects the clinical judgment process?
4. Answer Options
A. Document the findings and reassess in 4 hours
B. Apply oxygen and notify the provider immediately
C. Compare the findings with expected values and determine
whether the patient is deteriorating
D. Ask the nursing assistant to obtain a repeat vital sign set
5. Correct Answer
C
6. Detailed Rationale
Clinical judgment begins with recognizing cues and then
analyzing cues to determine whether the patient’s condition is
stable or worsening. An oxygen saturation of 90% and RR of 24
,may indicate early respiratory compromise, but the nurse
should first interpret the overall pattern before acting. This is
the thinking step that links assessment data to next actions.
7. Incorrect Option Analysis
• A. Incorrect. Delaying action without analysis may miss
deterioration.
o Common misconception: “If the patient is talking, the
oxygen level is acceptable.”
o Safety risk: Hypoxemia may worsen before
reassessment.
• B. Incorrect. Oxygen may be appropriate, but immediate
notification without prior analysis skips the judgment
process.
o Common misconception: “Any low saturation
requires escalation first.”
o Safety risk: Inefficient prioritization and incomplete
handoff.
• D. Incorrect. The nursing assistant can obtain data, but
this does not demonstrate the nurse’s own clinical
judgment.
o Common misconception: Delegating data collection
equals clinical reasoning.
o Safety risk: Delayed interpretation and intervention.
, 8. Nursing Process Linkage
Assessment
9. Clinical Judgment Competencies (NCJMM)
Recognize Cues, Analyze Cues
10. Difficulty Level
Moderate
11. Bloom’s Cognitive Level
Analyze
12. NCLEX Client Needs Category
Reduction of Risk Potential
13. Key Learning Objective
Identify the first steps in clinical judgment when interpreting
early signs of patient deterioration.
Question 2 — MCQ
1. Question Number and Type
Q2 — MCQ
2. Clinical Scenario
A nurse is reviewing care priorities for a patient with multiple
chronic illnesses who was admitted after a fall.
3. Question Stem
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
,Question 1 — MCQ
1. Question Number and Type
Q1 — MCQ
2. Clinical Scenario
A new graduate nurse is caring for a patient admitted with
pneumonia. During report, the nurse notes that the patient has
an oxygen saturation of 90% on room air, a respiratory rate of
24/min, and is speaking in full sentences.
3. Question Stem
Which action best reflects the clinical judgment process?
4. Answer Options
A. Document the findings and reassess in 4 hours
B. Apply oxygen and notify the provider immediately
C. Compare the findings with expected values and determine
whether the patient is deteriorating
D. Ask the nursing assistant to obtain a repeat vital sign set
5. Correct Answer
C
6. Detailed Rationale
Clinical judgment begins with recognizing cues and then
analyzing cues to determine whether the patient’s condition is
stable or worsening. An oxygen saturation of 90% and RR of 24
,may indicate early respiratory compromise, but the nurse
should first interpret the overall pattern before acting. This is
the thinking step that links assessment data to next actions.
7. Incorrect Option Analysis
• A. Incorrect. Delaying action without analysis may miss
deterioration.
o Common misconception: “If the patient is talking, the
oxygen level is acceptable.”
o Safety risk: Hypoxemia may worsen before
reassessment.
• B. Incorrect. Oxygen may be appropriate, but immediate
notification without prior analysis skips the judgment
process.
o Common misconception: “Any low saturation
requires escalation first.”
o Safety risk: Inefficient prioritization and incomplete
handoff.
• D. Incorrect. The nursing assistant can obtain data, but
this does not demonstrate the nurse’s own clinical
judgment.
o Common misconception: Delegating data collection
equals clinical reasoning.
o Safety risk: Delayed interpretation and intervention.
, 8. Nursing Process Linkage
Assessment
9. Clinical Judgment Competencies (NCJMM)
Recognize Cues, Analyze Cues
10. Difficulty Level
Moderate
11. Bloom’s Cognitive Level
Analyze
12. NCLEX Client Needs Category
Reduction of Risk Potential
13. Key Learning Objective
Identify the first steps in clinical judgment when interpreting
early signs of patient deterioration.
Question 2 — MCQ
1. Question Number and Type
Q2 — MCQ
2. Clinical Scenario
A nurse is reviewing care priorities for a patient with multiple
chronic illnesses who was admitted after a fall.
3. Question Stem
