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
Question Number and Type: 1 — MCQ
Clinical Scenario:
A newly hired nurse is assigned to a medical-surgical unit.
During report, a patient with heart failure is described as
“stable,” but the nurse notes the patient has new confusion,
increased respiratory rate, and oxygen saturation of 90% on
room air.
Question Stem:
Which action best reflects the first step in clinical judgment?
Answer Options:
A. Document the findings and continue the assignment
B. Recognize that the patient’s condition may be deteriorating
C. Administer oxygen after checking the care plan
D. Ask the charge nurse to reassess the patient later
Correct Answer:
B. Recognize that the patient’s condition may be deteriorating
Detailed Rationale:
The first step in clinical judgment is to recognize cues. New
confusion, tachypnea, and low oxygen saturation are
concerning cues that suggest potential deterioration. Early
recognition promotes timely escalation and prevents delay in
care.
Incorrect Option Analysis:
,• A. Document the findings and continue the assignment
o Why incorrect: Documentation is important, but it
should not replace immediate recognition and
response.
o Common misconception: Thinking charting is the first
priority when a patient shows signs of instability.
o Safety risk: Delayed intervention may worsen hypoxia
and lead to respiratory failure.
• C. Administer oxygen after checking the care plan
o Why incorrect: Intervention may be needed, but the
nurse must first recognize the abnormal cues and
determine urgency.
o Common misconception: Jumping straight to an
intervention without clinical analysis.
o Safety risk: The patient may require a broader rapid-
response evaluation, not just oxygen.
• D. Ask the charge nurse to reassess the patient later
o Why incorrect: Delaying assessment can be unsafe in
a potentially deteriorating patient.
o Common misconception: Assuming someone else can
address it later without escalation.
o Safety risk: Missed early warning signs and delayed
treatment.
, Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify early cues of patient deterioration and prioritize
recognition as the first clinical judgment action.
2) MCQ
Question Number and Type: 2 — MCQ
Clinical Scenario:
A nurse is caring for a patient admitted with dehydration. The
nurse compares the current assessment with the previous
shift’s findings.
Question Stem:
Which nursing action best demonstrates evidence-based
nursing care?
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Question Number and Type: 1 — MCQ
Clinical Scenario:
A newly hired nurse is assigned to a medical-surgical unit.
During report, a patient with heart failure is described as
“stable,” but the nurse notes the patient has new confusion,
increased respiratory rate, and oxygen saturation of 90% on
room air.
Question Stem:
Which action best reflects the first step in clinical judgment?
Answer Options:
A. Document the findings and continue the assignment
B. Recognize that the patient’s condition may be deteriorating
C. Administer oxygen after checking the care plan
D. Ask the charge nurse to reassess the patient later
Correct Answer:
B. Recognize that the patient’s condition may be deteriorating
Detailed Rationale:
The first step in clinical judgment is to recognize cues. New
confusion, tachypnea, and low oxygen saturation are
concerning cues that suggest potential deterioration. Early
recognition promotes timely escalation and prevents delay in
care.
Incorrect Option Analysis:
,• A. Document the findings and continue the assignment
o Why incorrect: Documentation is important, but it
should not replace immediate recognition and
response.
o Common misconception: Thinking charting is the first
priority when a patient shows signs of instability.
o Safety risk: Delayed intervention may worsen hypoxia
and lead to respiratory failure.
• C. Administer oxygen after checking the care plan
o Why incorrect: Intervention may be needed, but the
nurse must first recognize the abnormal cues and
determine urgency.
o Common misconception: Jumping straight to an
intervention without clinical analysis.
o Safety risk: The patient may require a broader rapid-
response evaluation, not just oxygen.
• D. Ask the charge nurse to reassess the patient later
o Why incorrect: Delaying assessment can be unsafe in
a potentially deteriorating patient.
o Common misconception: Assuming someone else can
address it later without escalation.
o Safety risk: Missed early warning signs and delayed
treatment.
, Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify early cues of patient deterioration and prioritize
recognition as the first clinical judgment action.
2) MCQ
Question Number and Type: 2 — MCQ
Clinical Scenario:
A nurse is caring for a patient admitted with dehydration. The
nurse compares the current assessment with the previous
shift’s findings.
Question Stem:
Which nursing action best demonstrates evidence-based
nursing care?
