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
,Scenario: An RN is assessing a newly admitted adult patient.
The patient reports feeling “a little off,” and the nurse notes a
respiratory rate increased from 16/min to 28/min and new
restlessness.
Stem: Which clinical judgment action is the nurse performing
first?
Options:
A. Recognize cues
B. Prioritize hypotheses
C. Take action
D. Evaluate outcomes
Correct Answer: A. Recognize cues
Rationale: The nurse is identifying abnormal data and detecting
changes from baseline. Recognizing cues is the first step in
clinical judgment and includes collecting and noticing relevant
assessment findings such as tachypnea and restlessness, which
may signal deterioration.
Incorrect Option Analysis:
• B. Prioritize hypotheses: Incorrect because the nurse has
not yet interpreted the meaning of the findings.
Misconception: jumping to conclusions too early. Risk:
delayed or inappropriate response.
• C. Take action: Incorrect because action should follow
analysis and prioritization. Misconception: acting before
understanding the problem. Risk: ineffective interventions.
, • D. Evaluate outcomes: Incorrect because evaluation
occurs after intervention. Misconception: skipping the
assessment phase. Risk: failure to identify the true cause
of deterioration.
Nursing Process Linkage: Assessment
NCJMM Competency: Recognize Cues
Difficulty: Easy
Bloom’s Level: Understand
NCLEX Client Needs: Reduction of Risk Potential
Key Learning Objective: Identify abnormal assessment data as
the first step in clinical judgment.
2) MCQ
Scenario: A medical-surgical unit is revising its pressure injury
prevention practice.
Stem: Which action best reflects evidence-based nursing care?
Options:
A. Continue the turning schedule used for years because it is
familiar
B. Use the plan that the most experienced nurse prefers
C. Review current clinical guidelines and patient-specific risk
factors
D. Ask the patient what position feels most comfortable and
use that only
, Correct Answer: C. Review current clinical guidelines and
patient-specific risk factors
Rationale: Evidence-based care combines best research
evidence, clinical expertise, and patient values. Reviewing
current guidelines and matching interventions to the patient’s
risks is the strongest evidence-based approach.
Incorrect Option Analysis:
• A. Continue the turning schedule used for years because
it is familiar: Incorrect because tradition alone is not
evidence. Misconception: “old practice equals best
practice.” Risk: outdated care.
• B. Use the plan that the most experienced nurse prefers:
Incorrect because expertise matters, but it must be
balanced with evidence and patient needs. Risk:
inconsistent or noncurrent care.
• D. Ask the patient what position feels most comfortable
and use that only: Incorrect because comfort is important,
but it does not replace pressure injury prevention
standards. Risk: skin breakdown.
Nursing Process Linkage: Planning
NCJMM Competency: Generate Solutions
Difficulty: Moderate
Bloom’s Level: Analyze
NCLEX Client Needs: Safety and Infection Control
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
1) MCQ
,Scenario: An RN is assessing a newly admitted adult patient.
The patient reports feeling “a little off,” and the nurse notes a
respiratory rate increased from 16/min to 28/min and new
restlessness.
Stem: Which clinical judgment action is the nurse performing
first?
Options:
A. Recognize cues
B. Prioritize hypotheses
C. Take action
D. Evaluate outcomes
Correct Answer: A. Recognize cues
Rationale: The nurse is identifying abnormal data and detecting
changes from baseline. Recognizing cues is the first step in
clinical judgment and includes collecting and noticing relevant
assessment findings such as tachypnea and restlessness, which
may signal deterioration.
Incorrect Option Analysis:
• B. Prioritize hypotheses: Incorrect because the nurse has
not yet interpreted the meaning of the findings.
Misconception: jumping to conclusions too early. Risk:
delayed or inappropriate response.
• C. Take action: Incorrect because action should follow
analysis and prioritization. Misconception: acting before
understanding the problem. Risk: ineffective interventions.
, • D. Evaluate outcomes: Incorrect because evaluation
occurs after intervention. Misconception: skipping the
assessment phase. Risk: failure to identify the true cause
of deterioration.
Nursing Process Linkage: Assessment
NCJMM Competency: Recognize Cues
Difficulty: Easy
Bloom’s Level: Understand
NCLEX Client Needs: Reduction of Risk Potential
Key Learning Objective: Identify abnormal assessment data as
the first step in clinical judgment.
2) MCQ
Scenario: A medical-surgical unit is revising its pressure injury
prevention practice.
Stem: Which action best reflects evidence-based nursing care?
Options:
A. Continue the turning schedule used for years because it is
familiar
B. Use the plan that the most experienced nurse prefers
C. Review current clinical guidelines and patient-specific risk
factors
D. Ask the patient what position feels most comfortable and
use that only
, Correct Answer: C. Review current clinical guidelines and
patient-specific risk factors
Rationale: Evidence-based care combines best research
evidence, clinical expertise, and patient values. Reviewing
current guidelines and matching interventions to the patient’s
risks is the strongest evidence-based approach.
Incorrect Option Analysis:
• A. Continue the turning schedule used for years because
it is familiar: Incorrect because tradition alone is not
evidence. Misconception: “old practice equals best
practice.” Risk: outdated care.
• B. Use the plan that the most experienced nurse prefers:
Incorrect because expertise matters, but it must be
balanced with evidence and patient needs. Risk:
inconsistent or noncurrent care.
• D. Ask the patient what position feels most comfortable
and use that only: Incorrect because comfort is important,
but it does not replace pressure injury prevention
standards. Risk: skin breakdown.
Nursing Process Linkage: Planning
NCJMM Competency: Generate Solutions
Difficulty: Moderate
Bloom’s Level: Analyze
NCLEX Client Needs: Safety and Infection Control
