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 RN begins work on a busy medical-surgical
unit. During morning rounds, the nurse notices that a patient
recovering from abdominal surgery appears more restless than
earlier, reports increasing pain despite prescribed analgesia,
and has a heart rate of 118 beats/min. The surgical dressing
remains dry and intact.
Question Stem
Which nursing action best demonstrates clinical judgment?
Answer Options
A. Administer the next scheduled pain medication and reassess
in four hours.
B. Recognize the abnormal findings, perform a focused
assessment, review vital signs and trends, and notify the
provider if deterioration is suspected.
C. Document the findings because postoperative pain
commonly increases during recovery.
D. Ask the nursing assistant to repeat the patient's vital signs
later in the shift.
Correct Answer
B
,Detailed Rationale
Clinical judgment involves recognizing subtle cues, analyzing
their significance, prioritizing possible causes, and initiating
timely interventions. Restlessness, tachycardia, and worsening
pain may indicate early postoperative complications such as
hemorrhage, infection, or inadequate tissue perfusion. A
focused assessment and prompt escalation promote early
recognition of deterioration and improve patient safety.
Incorrect Option Analysis
Option A
Why Incorrect
Pain medication alone addresses symptoms without
investigating the underlying cause.
Common Misconception
Assuming all postoperative pain is expected.
Patient Safety Risk
Delayed recognition of life-threatening complications.
Option C
Why Incorrect
, Documentation alone does not address potentially worsening
physiologic changes.
Common Misconception
Believing documentation replaces intervention.
Patient Safety Risk
Missed opportunity for early treatment.
Option D
Why Incorrect
Repeating vital signs later unnecessarily delays assessment.
Common Misconception
Waiting for more obvious symptoms before acting.
Patient Safety Risk
Progression to clinical instability.
Nursing Process Linkage
Assessment
NCJMM Competencies
• Recognize Cues
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 RN begins work on a busy medical-surgical
unit. During morning rounds, the nurse notices that a patient
recovering from abdominal surgery appears more restless than
earlier, reports increasing pain despite prescribed analgesia,
and has a heart rate of 118 beats/min. The surgical dressing
remains dry and intact.
Question Stem
Which nursing action best demonstrates clinical judgment?
Answer Options
A. Administer the next scheduled pain medication and reassess
in four hours.
B. Recognize the abnormal findings, perform a focused
assessment, review vital signs and trends, and notify the
provider if deterioration is suspected.
C. Document the findings because postoperative pain
commonly increases during recovery.
D. Ask the nursing assistant to repeat the patient's vital signs
later in the shift.
Correct Answer
B
,Detailed Rationale
Clinical judgment involves recognizing subtle cues, analyzing
their significance, prioritizing possible causes, and initiating
timely interventions. Restlessness, tachycardia, and worsening
pain may indicate early postoperative complications such as
hemorrhage, infection, or inadequate tissue perfusion. A
focused assessment and prompt escalation promote early
recognition of deterioration and improve patient safety.
Incorrect Option Analysis
Option A
Why Incorrect
Pain medication alone addresses symptoms without
investigating the underlying cause.
Common Misconception
Assuming all postoperative pain is expected.
Patient Safety Risk
Delayed recognition of life-threatening complications.
Option C
Why Incorrect
, Documentation alone does not address potentially worsening
physiologic changes.
Common Misconception
Believing documentation replaces intervention.
Patient Safety Risk
Missed opportunity for early treatment.
Option D
Why Incorrect
Repeating vital signs later unnecessarily delays assessment.
Common Misconception
Waiting for more obvious symptoms before acting.
Patient Safety Risk
Progression to clinical instability.
Nursing Process Linkage
Assessment
NCJMM Competencies
• Recognize Cues
