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 newly licensed nurse is caring for a 72-year-old patient
admitted with community-acquired pneumonia. During
assessment, the nurse notes increasing confusion, a respiratory
rate of 30 breaths/min, oxygen saturation of 88% on room air,
and use of accessory muscles.
Question Stem
Which nursing action best demonstrates effective clinical
judgment?
Options
A. Continue routine assessment and document findings at the
end of the shift.
B. Immediately notify the provider and initiate interventions
according to facility protocols.
C. Reassure the patient that confusion is expected in older
adults.
D. Delegate reassessment of respiratory status to an unlicensed
assistive personnel (UAP).
Correct Answer
B. Immediately notify the provider and initiate interventions
according to facility protocols.
Detailed Rationale
The patient exhibits signs of respiratory deterioration, including
hypoxemia, tachypnea, altered mental status, and increased
,work of breathing. Effective clinical judgment requires
recognizing cues, analyzing their significance, prioritizing
patient needs, and taking timely action. Early intervention can
prevent progression to respiratory failure.
Incorrect Option Analysis
A. Continue routine assessment
Why Incorrect: Delays intervention.
Common Misconception: Documentation alone improves
outcomes.
Safety Risk: Potential respiratory arrest.
C. Reassure patient
Why Incorrect: Confusion may indicate hypoxia.
Common Misconception: All confusion in older adults is
normal.
Safety Risk: Missed deterioration.
D. Delegate reassessment
Why Incorrect: Assessment requires RN judgment.
Common Misconception: All tasks can be delegated.
Safety Risk: Delayed recognition of worsening condition.
Nursing Process Linkage
Assessment
NCJMM Competencies
, • Recognize Cues
• Analyze Cues
• Prioritize Hypotheses
• Take Action
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Category
Physiological Adaptation
Learning Objective
Apply clinical judgment principles to identify and respond to
patient deterioration.
Question 2 (SATA)
Clinical Scenario
A nurse is implementing evidence-based practices to reduce
catheter-associated urinary tract infections (CAUTIs).
Question Stem
Which interventions are supported by evidence-based practice?
Select all that apply.
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 newly licensed nurse is caring for a 72-year-old patient
admitted with community-acquired pneumonia. During
assessment, the nurse notes increasing confusion, a respiratory
rate of 30 breaths/min, oxygen saturation of 88% on room air,
and use of accessory muscles.
Question Stem
Which nursing action best demonstrates effective clinical
judgment?
Options
A. Continue routine assessment and document findings at the
end of the shift.
B. Immediately notify the provider and initiate interventions
according to facility protocols.
C. Reassure the patient that confusion is expected in older
adults.
D. Delegate reassessment of respiratory status to an unlicensed
assistive personnel (UAP).
Correct Answer
B. Immediately notify the provider and initiate interventions
according to facility protocols.
Detailed Rationale
The patient exhibits signs of respiratory deterioration, including
hypoxemia, tachypnea, altered mental status, and increased
,work of breathing. Effective clinical judgment requires
recognizing cues, analyzing their significance, prioritizing
patient needs, and taking timely action. Early intervention can
prevent progression to respiratory failure.
Incorrect Option Analysis
A. Continue routine assessment
Why Incorrect: Delays intervention.
Common Misconception: Documentation alone improves
outcomes.
Safety Risk: Potential respiratory arrest.
C. Reassure patient
Why Incorrect: Confusion may indicate hypoxia.
Common Misconception: All confusion in older adults is
normal.
Safety Risk: Missed deterioration.
D. Delegate reassessment
Why Incorrect: Assessment requires RN judgment.
Common Misconception: All tasks can be delegated.
Safety Risk: Delayed recognition of worsening condition.
Nursing Process Linkage
Assessment
NCJMM Competencies
, • Recognize Cues
• Analyze Cues
• Prioritize Hypotheses
• Take Action
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Category
Physiological Adaptation
Learning Objective
Apply clinical judgment principles to identify and respond to
patient deterioration.
Question 2 (SATA)
Clinical Scenario
A nurse is implementing evidence-based practices to reduce
catheter-associated urinary tract infections (CAUTIs).
Question Stem
Which interventions are supported by evidence-based practice?
Select all that apply.
