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
Question 1
Type: MCQ
Clinical Scenario: A postoperative client is 2 hours after
abdominal surgery. The nurse notes a respiratory rate of 8/min,
shallow breathing, oxygen saturation of 88% on 2 L nasal
cannula, and the client is difficult to arouse after receiving IV
morphine 20 minutes ago.
Question Stem: What is the nurse’s priority action?
Answer Options:
A. Activate the rapid response team
B. Document the response to morphine
C. Encourage the client to cough and deep breathe
D. Administer the next scheduled pain dose
Correct Answer: A. Activate the rapid response team
Detailed Rationale:
This client shows acute deterioration consistent with opioid-
induced respiratory depression and hypoxemia. The safest
priority is to summon immediate help so airway and breathing
can be supported without delay. In a rapidly worsening
situation, escalation is a key nursing action.
Incorrect Option Analysis:
• B. Document the response to morphine — Incorrect
because documentation follows immediate stabilization.
, o Misconception: Charting is not the first priority in
deterioration.
o Safety risk: Delayed rescue can worsen hypoxia and
cause arrest.
• C. Encourage cough and deep breathe — Incorrect
because this is insufficient for severe respiratory
depression.
o Misconception: A simple breathing exercise can
correct medication-induced hypoventilation.
o Safety risk: The client may continue to deteriorate.
• D. Administer the next scheduled pain dose — Incorrect
and unsafe.
o Misconception: Pain management should continue
without reassessing sedation.
o Safety risk: Further respiratory compromise.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues; Prioritize Hypotheses;
Take Action
Difficulty Level: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Recognize signs of acute respiratory
compromise and prioritize escalation of care.
, Question 2
Type: MCQ
Clinical Scenario: A newly diagnosed client with type 2 diabetes
is being discharged with a new insulin regimen. The client has
limited health literacy and says, “I get confused when
instructions have too many words.”
Question Stem: Which teaching method is best?
Answer Options:
A. Provide a detailed printed packet and ask the client to read it
at home
B. Use teach-back and return demonstration for insulin
administration
C. Tell the client to ask the pharmacist if questions arise
D. Focus only on the most important dose and skip other
teaching
Correct Answer: B. Use teach-back and return demonstration
for insulin administration
Detailed Rationale:
Teach-back confirms understanding, and return demonstration
verifies the client can safely perform the skill. This is patient-
centered, evidence-informed teaching for limited health
literacy.
Incorrect Option Analysis:
• A. Provide a detailed printed packet — Incorrect because
written material alone may not be understood.
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
Question 1
Type: MCQ
Clinical Scenario: A postoperative client is 2 hours after
abdominal surgery. The nurse notes a respiratory rate of 8/min,
shallow breathing, oxygen saturation of 88% on 2 L nasal
cannula, and the client is difficult to arouse after receiving IV
morphine 20 minutes ago.
Question Stem: What is the nurse’s priority action?
Answer Options:
A. Activate the rapid response team
B. Document the response to morphine
C. Encourage the client to cough and deep breathe
D. Administer the next scheduled pain dose
Correct Answer: A. Activate the rapid response team
Detailed Rationale:
This client shows acute deterioration consistent with opioid-
induced respiratory depression and hypoxemia. The safest
priority is to summon immediate help so airway and breathing
can be supported without delay. In a rapidly worsening
situation, escalation is a key nursing action.
Incorrect Option Analysis:
• B. Document the response to morphine — Incorrect
because documentation follows immediate stabilization.
, o Misconception: Charting is not the first priority in
deterioration.
o Safety risk: Delayed rescue can worsen hypoxia and
cause arrest.
• C. Encourage cough and deep breathe — Incorrect
because this is insufficient for severe respiratory
depression.
o Misconception: A simple breathing exercise can
correct medication-induced hypoventilation.
o Safety risk: The client may continue to deteriorate.
• D. Administer the next scheduled pain dose — Incorrect
and unsafe.
o Misconception: Pain management should continue
without reassessing sedation.
o Safety risk: Further respiratory compromise.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues; Prioritize Hypotheses;
Take Action
Difficulty Level: Difficult
Bloom’s Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Recognize signs of acute respiratory
compromise and prioritize escalation of care.
, Question 2
Type: MCQ
Clinical Scenario: A newly diagnosed client with type 2 diabetes
is being discharged with a new insulin regimen. The client has
limited health literacy and says, “I get confused when
instructions have too many words.”
Question Stem: Which teaching method is best?
Answer Options:
A. Provide a detailed printed packet and ask the client to read it
at home
B. Use teach-back and return demonstration for insulin
administration
C. Tell the client to ask the pharmacist if questions arise
D. Focus only on the most important dose and skip other
teaching
Correct Answer: B. Use teach-back and return demonstration
for insulin administration
Detailed Rationale:
Teach-back confirms understanding, and return demonstration
verifies the client can safely perform the skill. This is patient-
centered, evidence-informed teaching for limited health
literacy.
Incorrect Option Analysis:
• A. Provide a detailed printed packet — Incorrect because
written material alone may not be understood.
