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 (MCQ)
Clinical Scenario
A nurse begins a shift caring for four patients on a medical-
surgical unit. During report, the nurse learns that one patient
has developed new-onset confusion and restlessness over the
past hour.
Question Stem
Which action best demonstrates the nurse's use of clinical
judgment?
Answer Options
A. Administer a prescribed sedative immediately
B. Recognize the change in mental status, assess the patient,
and determine possible causes
C. Notify the healthcare provider before assessing the patient
D. Reassure the patient that confusion is common during
hospitalization
Correct Answer
B. Recognize the change in mental status, assess the patient,
and determine possible causes
Detailed Rationale
Clinical judgment begins with recognizing cues and gathering
relevant assessment data. New-onset confusion may indicate
hypoxia, infection, medication effects, metabolic imbalance, or
,neurologic deterioration. The nurse should assess before taking
further action.
Incorrect Option Analysis
A. Administer a prescribed sedative immediately
• Why Incorrect: Cause of confusion has not been identified.
• Common Misconception: Agitation always requires
sedation.
• Safety Risk: May mask deterioration.
C. Notify provider before assessing
• Why Incorrect: Assessment should occur first.
• Common Misconception: Reporting comes before nursing
assessment.
• Safety Risk: Incomplete information delays treatment.
D. Reassure patient
• Why Incorrect: Does not address underlying cause.
• Common Misconception: Confusion is expected in
hospitalized adults.
• Safety Risk: Missed deterioration.
Nursing Process Linkage
Assessment
NCJMM Competencies
, • Recognize Cues
• Analyze Cues
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Client Needs
Physiological Adaptation
Learning Objective
Apply clinical judgment principles when recognizing early signs
of patient deterioration.
Question 2 (MCQ)
Clinical Scenario
A nurse reviews recent literature regarding prevention of
catheter-associated urinary tract infections (CAUTIs).
Question Stem
Which action reflects evidence-based nursing practice?
Options
A. Using interventions because they have always been
performed that way
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
-
TEST BANK
,Question 1 (MCQ)
Clinical Scenario
A nurse begins a shift caring for four patients on a medical-
surgical unit. During report, the nurse learns that one patient
has developed new-onset confusion and restlessness over the
past hour.
Question Stem
Which action best demonstrates the nurse's use of clinical
judgment?
Answer Options
A. Administer a prescribed sedative immediately
B. Recognize the change in mental status, assess the patient,
and determine possible causes
C. Notify the healthcare provider before assessing the patient
D. Reassure the patient that confusion is common during
hospitalization
Correct Answer
B. Recognize the change in mental status, assess the patient,
and determine possible causes
Detailed Rationale
Clinical judgment begins with recognizing cues and gathering
relevant assessment data. New-onset confusion may indicate
hypoxia, infection, medication effects, metabolic imbalance, or
,neurologic deterioration. The nurse should assess before taking
further action.
Incorrect Option Analysis
A. Administer a prescribed sedative immediately
• Why Incorrect: Cause of confusion has not been identified.
• Common Misconception: Agitation always requires
sedation.
• Safety Risk: May mask deterioration.
C. Notify provider before assessing
• Why Incorrect: Assessment should occur first.
• Common Misconception: Reporting comes before nursing
assessment.
• Safety Risk: Incomplete information delays treatment.
D. Reassure patient
• Why Incorrect: Does not address underlying cause.
• Common Misconception: Confusion is expected in
hospitalized adults.
• Safety Risk: Missed deterioration.
Nursing Process Linkage
Assessment
NCJMM Competencies
, • Recognize Cues
• Analyze Cues
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Client Needs
Physiological Adaptation
Learning Objective
Apply clinical judgment principles when recognizing early signs
of patient deterioration.
Question 2 (MCQ)
Clinical Scenario
A nurse reviews recent literature regarding prevention of
catheter-associated urinary tract infections (CAUTIs).
Question Stem
Which action reflects evidence-based nursing practice?
Options
A. Using interventions because they have always been
performed that way
