Davis Advantage for Medical-
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
-
TEST BANK
Question 1
,Type
MCQ
Clinical Scenario
A newly licensed nurse is caring for a 68-year-old patient
admitted with community-acquired pneumonia. During the
morning assessment, the nurse notes an oxygen saturation of
88% on room air, respiratory rate of 28 breaths/minute, and
increasing confusion compared with the previous shift.
Question Stem
Which nursing action best demonstrates the use of clinical
judgment?
Answer Options
A. Document the findings and continue the assessment.
B. Notify the provider immediately after recognizing the
abnormal findings and initiate oxygen per protocol.
C. Reassure the patient that confusion is common in older
adults.
D. Wait for the provider's rounds to discuss the findings.
Correct Answer
B. Notify the provider immediately after recognizing the
abnormal findings and initiate oxygen per protocol.
Detailed Rationale
,Clinical judgment requires the nurse to recognize significant
cues, analyze their meaning, prioritize patient needs, and take
action. Hypoxemia, tachypnea, and acute confusion indicate
potential respiratory deterioration. Prompt intervention can
prevent progression to respiratory failure. Initiating oxygen
according to protocol while communicating findings
demonstrates effective clinical judgment and patient-centered
care.
Incorrect Option Analysis
A. Document the findings and continue the assessment.
• Why Incorrect: Delays intervention.
• Common Misconception: Documentation alone addresses
abnormal findings.
• Patient Safety Risk: Worsening hypoxia and delayed
treatment.
C. Reassure the patient that confusion is common in older
adults.
• Why Incorrect: Acute confusion is not an expected finding.
• Common Misconception: All confusion in older adults is
normal aging.
• Patient Safety Risk: Failure to identify deterioration.
D. Wait for provider rounds.
• Why Incorrect: The patient requires immediate attention.
, • Common Misconception: All changes can wait for routine
rounds.
• Patient Safety Risk: Increased risk of respiratory
compromise.
Nursing Process Linkage
Implementation
NCJMM Competencies
• Recognize Cues
• Analyze Cues
• Prioritize Hypotheses
• Take Action
Difficulty
Moderate
Bloom's Level
Apply
NCLEX Client Needs Category
Physiological Adaptation
Key Learning Objective
Apply clinical judgment principles to recognize and respond to
patient deterioration.
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
-
TEST BANK
Question 1
,Type
MCQ
Clinical Scenario
A newly licensed nurse is caring for a 68-year-old patient
admitted with community-acquired pneumonia. During the
morning assessment, the nurse notes an oxygen saturation of
88% on room air, respiratory rate of 28 breaths/minute, and
increasing confusion compared with the previous shift.
Question Stem
Which nursing action best demonstrates the use of clinical
judgment?
Answer Options
A. Document the findings and continue the assessment.
B. Notify the provider immediately after recognizing the
abnormal findings and initiate oxygen per protocol.
C. Reassure the patient that confusion is common in older
adults.
D. Wait for the provider's rounds to discuss the findings.
Correct Answer
B. Notify the provider immediately after recognizing the
abnormal findings and initiate oxygen per protocol.
Detailed Rationale
,Clinical judgment requires the nurse to recognize significant
cues, analyze their meaning, prioritize patient needs, and take
action. Hypoxemia, tachypnea, and acute confusion indicate
potential respiratory deterioration. Prompt intervention can
prevent progression to respiratory failure. Initiating oxygen
according to protocol while communicating findings
demonstrates effective clinical judgment and patient-centered
care.
Incorrect Option Analysis
A. Document the findings and continue the assessment.
• Why Incorrect: Delays intervention.
• Common Misconception: Documentation alone addresses
abnormal findings.
• Patient Safety Risk: Worsening hypoxia and delayed
treatment.
C. Reassure the patient that confusion is common in older
adults.
• Why Incorrect: Acute confusion is not an expected finding.
• Common Misconception: All confusion in older adults is
normal aging.
• Patient Safety Risk: Failure to identify deterioration.
D. Wait for provider rounds.
• Why Incorrect: The patient requires immediate attention.
, • Common Misconception: All changes can wait for routine
rounds.
• Patient Safety Risk: Increased risk of respiratory
compromise.
Nursing Process Linkage
Implementation
NCJMM Competencies
• Recognize Cues
• Analyze Cues
• Prioritize Hypotheses
• Take Action
Difficulty
Moderate
Bloom's Level
Apply
NCLEX Client Needs Category
Physiological Adaptation
Key Learning Objective
Apply clinical judgment principles to recognize and respond to
patient deterioration.
