Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Clinical Scenario
A nurse is assessing a patient newly admitted to the medical-
surgical unit with shortness of breath.
Question Stem
Which finding is an objective cue?
Answer Options
A. “I feel anxious.”
B. “My chest feels tight.”
C. Respiratory rate of 28/min
D. “I cannot catch my breath.”
Correct Answer
C. Respiratory rate of 28/min
Detailed Rationale
Objective data are observable and measurable. Respiratory rate
is a direct, countable assessment finding, so it is an objective
cue. The other options are subjective statements reported by
the patient and must be validated with assessment data.
Incorrect Option Analysis
• A. “I feel anxious.”
, o Why incorrect: This is a subjective symptom reported
by the patient.
o Common misconception: Believing emotional
statements are objective because they may be visible
in behavior.
o Safety risk: Overreliance on subjective statements
can delay recognition of physiologic deterioration.
• B. “My chest feels tight.”
o Why incorrect: Subjective symptom, not measurable
by the nurse.
o Common misconception: Treating symptom reports
as objective because they may indicate a problem.
o Safety risk: Could lead to incomplete assessment if
not paired with objective data.
• D. “I cannot catch my breath.”
o Why incorrect: This is subjective patient-reported
dyspnea.
o Common misconception: Assuming a dramatic
symptom report is more clinically valid than objective
data.
o Safety risk: May obscure the need to quantify
breathing status.
Nursing Process Linkage
, Assessment
Clinical Judgment Competencies (NCJMM)
Recognize Cues
Difficulty Level
Easy
Bloom’s Cognitive Level
Understand
NCLEX Client Needs Category
Physiological Adaptation
Key Learning Objective
Differentiate objective and subjective assessment data.
2) MCQ
Clinical Scenario
A nurse identifies that a patient with pneumonia has an
elevated temperature, productive cough, and oxygen
saturation of 91% on room air.
Question Stem
Which action best demonstrates the planning phase of the
nursing process?
Answer Options