Davis Advantage for Medical-
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 caring for a postoperative patient who becomes
difficult to arouse after receiving an opioid analgesic. The
patient’s respiratory rate is 10/min, oxygen saturation is 89%
on room air, and the skin is cool and pale.
Question Stem
What is the nurse’s priority action?
Answer Options
A. Reposition the patient and encourage coughing and deep
breathing
B. Administer the next scheduled opioid dose to prevent pain
escalation
C. Assess airway, apply oxygen per protocol, and summon
assistance
D. Document the findings and reassess the patient in 30
minutes
Correct Answer
C. Assess airway, apply oxygen per protocol, and summon
assistance
Detailed Rationale
The patient shows cues of opioid-related respiratory
depression: decreased level of consciousness, low respiratory
,rate, and low oxygen saturation. The nurse must act using the
ABC priority framework, starting with airway and breathing.
Immediate support with oxygen and escalation of care are
appropriate while further assessment continues.
Incorrect Option Analysis
• A: Repositioning and deep breathing may help mild
atelectasis, but they do not address possible respiratory
depression.
o Misconception: Thinking all low oxygen situations are
fixed with breathing exercises.
o Risk: Delayed response to a potentially life-
threatening decline.
• B: Giving more opioid worsens respiratory depression.
o Misconception: Assuming uncontrolled pain is the
main issue when breathing is impaired.
o Risk: Respiratory arrest.
• D: Waiting is unsafe with abnormal breathing and
hypoxemia.
o Misconception: Believing reassessment can replace
immediate action.
o Risk: Rapid deterioration without timely intervention.
Nursing Process Linkage
Implementation
, Clinical Judgment Competencies (NCJMM)
Recognize Cues; Analyze Cues; Take Action
Difficulty Level
Difficult
Bloom’s Cognitive Level
Analyze
NCLEX Client Needs Category
Physiological Adaptation
Key Learning Objective
Recognize deteriorating respiratory status and prioritize
immediate intervention.
2) MCQ
Clinical Scenario
A nursing unit wants to improve its fall-prevention practice
after several recent inpatient falls.
Question Stem
Which source best supports an evidence-informed practice
change?
Answer Options
A. A senior nurse’s personal preference based on years of
experience
B. A current clinical practice guideline plus unit fall data
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 caring for a postoperative patient who becomes
difficult to arouse after receiving an opioid analgesic. The
patient’s respiratory rate is 10/min, oxygen saturation is 89%
on room air, and the skin is cool and pale.
Question Stem
What is the nurse’s priority action?
Answer Options
A. Reposition the patient and encourage coughing and deep
breathing
B. Administer the next scheduled opioid dose to prevent pain
escalation
C. Assess airway, apply oxygen per protocol, and summon
assistance
D. Document the findings and reassess the patient in 30
minutes
Correct Answer
C. Assess airway, apply oxygen per protocol, and summon
assistance
Detailed Rationale
The patient shows cues of opioid-related respiratory
depression: decreased level of consciousness, low respiratory
,rate, and low oxygen saturation. The nurse must act using the
ABC priority framework, starting with airway and breathing.
Immediate support with oxygen and escalation of care are
appropriate while further assessment continues.
Incorrect Option Analysis
• A: Repositioning and deep breathing may help mild
atelectasis, but they do not address possible respiratory
depression.
o Misconception: Thinking all low oxygen situations are
fixed with breathing exercises.
o Risk: Delayed response to a potentially life-
threatening decline.
• B: Giving more opioid worsens respiratory depression.
o Misconception: Assuming uncontrolled pain is the
main issue when breathing is impaired.
o Risk: Respiratory arrest.
• D: Waiting is unsafe with abnormal breathing and
hypoxemia.
o Misconception: Believing reassessment can replace
immediate action.
o Risk: Rapid deterioration without timely intervention.
Nursing Process Linkage
Implementation
, Clinical Judgment Competencies (NCJMM)
Recognize Cues; Analyze Cues; Take Action
Difficulty Level
Difficult
Bloom’s Cognitive Level
Analyze
NCLEX Client Needs Category
Physiological Adaptation
Key Learning Objective
Recognize deteriorating respiratory status and prioritize
immediate intervention.
2) MCQ
Clinical Scenario
A nursing unit wants to improve its fall-prevention practice
after several recent inpatient falls.
Question Stem
Which source best supports an evidence-informed practice
change?
Answer Options
A. A senior nurse’s personal preference based on years of
experience
B. A current clinical practice guideline plus unit fall data
