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 newly hired nurse is caring for a 72-year-old patient on
postoperative day 1 after bowel surgery. During report, the
nurse notes that the patient’s heart rate is 118/min, respiratory
rate is 24/min, oxygen saturation is 92% on room air, and the
patient says, “Something just feels off.”
Question Stem
Which action best reflects the first step in clinical judgment?
Answer Options
A. Recognize and assess the cues to determine what is
abnormal
B. Contact the provider immediately with a diagnosis
C. Document the findings in the electronic health record
D. Give the patient prescribed pain medication first
Correct Answer
A
Detailed Rationale
Clinical judgment begins with recognizing cues. The patient has
multiple abnormal findings that require further assessment and
interpretation before action is taken. A nurse must identify
,what is expected versus unexpected, then analyze the data to
determine priorities.
Incorrect Option Analysis
• B. Contact the provider immediately with a diagnosis —
Incorrect because the nurse has not yet formed a nursing
diagnosis or prioritized the problem.
Common misconception: Thinking escalation must occur
before analysis.
Patient safety risk: Incomplete or inaccurate reporting can
delay appropriate care.
• C. Document the findings in the electronic health record
— Incorrect because documentation is important, but it
does not come before assessment and clinical
interpretation.
Common misconception: Recording data is the same as
acting on it.
Patient safety risk: Missed early intervention for
deterioration.
• D. Give the patient prescribed pain medication first —
Incorrect because pain may contribute, but the abnormal
vital signs and “feels off” statement require assessment
before medication.
Common misconception: Assuming discomfort is the
cause of all postoperative changes.
Patient safety risk: Masking deterioration such as
hypoxemia or bleeding.
, Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
Difficulty Level
Moderate
Bloom's Cognitive Level
Apply
NCLEX Client Needs Category
Reduction of Risk Potential
Key Learning Objective
Identify abnormal cues that require further assessment before
intervention.
2. MCQ
Clinical Scenario
A patient recovering from hip replacement tells the nurse, “I do
not want to get out of bed until tomorrow because I am afraid
it will hurt too much.” The patient’s spouse asks the nurse to
“just make the patient walk because that is what the doctor
wants.”
Question Stem
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,1. MCQ
Clinical Scenario
A newly hired nurse is caring for a 72-year-old patient on
postoperative day 1 after bowel surgery. During report, the
nurse notes that the patient’s heart rate is 118/min, respiratory
rate is 24/min, oxygen saturation is 92% on room air, and the
patient says, “Something just feels off.”
Question Stem
Which action best reflects the first step in clinical judgment?
Answer Options
A. Recognize and assess the cues to determine what is
abnormal
B. Contact the provider immediately with a diagnosis
C. Document the findings in the electronic health record
D. Give the patient prescribed pain medication first
Correct Answer
A
Detailed Rationale
Clinical judgment begins with recognizing cues. The patient has
multiple abnormal findings that require further assessment and
interpretation before action is taken. A nurse must identify
,what is expected versus unexpected, then analyze the data to
determine priorities.
Incorrect Option Analysis
• B. Contact the provider immediately with a diagnosis —
Incorrect because the nurse has not yet formed a nursing
diagnosis or prioritized the problem.
Common misconception: Thinking escalation must occur
before analysis.
Patient safety risk: Incomplete or inaccurate reporting can
delay appropriate care.
• C. Document the findings in the electronic health record
— Incorrect because documentation is important, but it
does not come before assessment and clinical
interpretation.
Common misconception: Recording data is the same as
acting on it.
Patient safety risk: Missed early intervention for
deterioration.
• D. Give the patient prescribed pain medication first —
Incorrect because pain may contribute, but the abnormal
vital signs and “feels off” statement require assessment
before medication.
Common misconception: Assuming discomfort is the
cause of all postoperative changes.
Patient safety risk: Masking deterioration such as
hypoxemia or bleeding.
, Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
Difficulty Level
Moderate
Bloom's Cognitive Level
Apply
NCLEX Client Needs Category
Reduction of Risk Potential
Key Learning Objective
Identify abnormal cues that require further assessment before
intervention.
2. MCQ
Clinical Scenario
A patient recovering from hip replacement tells the nurse, “I do
not want to get out of bed until tomorrow because I am afraid
it will hurt too much.” The patient’s spouse asks the nurse to
“just make the patient walk because that is what the doctor
wants.”
Question Stem
