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 new graduate nurse is caring for a patient
admitted with shortness of breath and fatigue. The patient’s
oxygen saturation is 89%, respiratory rate is 28/min, and
,accessory muscle use is present.
Question Stem: Which action best demonstrates the clinical
judgment competency of taking action?
Answer Options:
A. Document the findings at the end of the shift
B. Apply oxygen and notify the provider immediately
C. Reassess the patient in 30 minutes
D. Ask the nursing assistant to sit with the patient
Correct Answer: B
Detailed Rationale:
The patient shows signs of respiratory compromise. Applying
oxygen and promptly notifying the provider reflects immediate
action based on abnormal cues. This is consistent with the
clinical judgment process: recognizing deterioration, prioritizing
a probable airway/breathing problem, and intervening quickly
to improve oxygenation.
Incorrect Option Analysis:
• A: Incorrect. Delaying documentation without intervention
ignores unstable findings.
o Common misconception: Documentation is the
priority over immediate action.
o Safety risk: Respiratory failure could worsen.
• C: Incorrect. Waiting is unsafe for an unstable patient.
, o Common misconception: Mild delay is acceptable
when reassessment is planned.
o Safety risk: Hypoxemia may progress rapidly.
• D: Incorrect. The nursing assistant cannot manage this
clinical deterioration.
o Common misconception: Basic supervision replaces
nursing assessment and intervention.
o Safety risk: Delayed escalation of care.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify the immediate nursing action
for signs of respiratory instability.
2) SATA
Clinical Scenario: A medical-surgical nurse is reviewing
evidence-based care for preventing hospital-acquired infection.
Question Stem: Which actions are consistent with evidence-
based infection prevention? Select all that apply.
Answer Options:
A. Perform hand hygiene before and after patient contact
, B. Use alcohol-based hand rub when hands are not visibly
soiled
C. Wear sterile gloves for every patient interaction
D. Remove indwelling urinary catheters as soon as no longer
needed
E. Clean reusable equipment between patients
Correct Answers: A, B, D, E
Detailed Rationale:
Hand hygiene is the most effective infection prevention
measure. Alcohol-based hand rub is appropriate when hands
are not visibly soiled. Early removal of catheters reduces CAUTI
risk. Cleaning equipment prevents cross-contamination. These
actions reflect current infection control evidence and patient
safety standards.
Incorrect Option Analysis:
• C: Incorrect. Sterile gloves are not needed for routine
patient interaction.
o Common misconception: Sterile technique is
required for all contact.
o Safety risk: Wasted resources and false sense of
safety; may lead to poor adherence to proper
standard precautions.
Nursing Process Linkage: Implementation
NCJMM Competencies: Generate Solutions, Take Action
Difficulty Level: Easy
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
1) MCQ
Clinical Scenario: A new graduate nurse is caring for a patient
admitted with shortness of breath and fatigue. The patient’s
oxygen saturation is 89%, respiratory rate is 28/min, and
,accessory muscle use is present.
Question Stem: Which action best demonstrates the clinical
judgment competency of taking action?
Answer Options:
A. Document the findings at the end of the shift
B. Apply oxygen and notify the provider immediately
C. Reassess the patient in 30 minutes
D. Ask the nursing assistant to sit with the patient
Correct Answer: B
Detailed Rationale:
The patient shows signs of respiratory compromise. Applying
oxygen and promptly notifying the provider reflects immediate
action based on abnormal cues. This is consistent with the
clinical judgment process: recognizing deterioration, prioritizing
a probable airway/breathing problem, and intervening quickly
to improve oxygenation.
Incorrect Option Analysis:
• A: Incorrect. Delaying documentation without intervention
ignores unstable findings.
o Common misconception: Documentation is the
priority over immediate action.
o Safety risk: Respiratory failure could worsen.
• C: Incorrect. Waiting is unsafe for an unstable patient.
, o Common misconception: Mild delay is acceptable
when reassessment is planned.
o Safety risk: Hypoxemia may progress rapidly.
• D: Incorrect. The nursing assistant cannot manage this
clinical deterioration.
o Common misconception: Basic supervision replaces
nursing assessment and intervention.
o Safety risk: Delayed escalation of care.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues, Prioritize Hypotheses,
Take Action
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify the immediate nursing action
for signs of respiratory instability.
2) SATA
Clinical Scenario: A medical-surgical nurse is reviewing
evidence-based care for preventing hospital-acquired infection.
Question Stem: Which actions are consistent with evidence-
based infection prevention? Select all that apply.
Answer Options:
A. Perform hand hygiene before and after patient contact
, B. Use alcohol-based hand rub when hands are not visibly
soiled
C. Wear sterile gloves for every patient interaction
D. Remove indwelling urinary catheters as soon as no longer
needed
E. Clean reusable equipment between patients
Correct Answers: A, B, D, E
Detailed Rationale:
Hand hygiene is the most effective infection prevention
measure. Alcohol-based hand rub is appropriate when hands
are not visibly soiled. Early removal of catheters reduces CAUTI
risk. Cleaning equipment prevents cross-contamination. These
actions reflect current infection control evidence and patient
safety standards.
Incorrect Option Analysis:
• C: Incorrect. Sterile gloves are not needed for routine
patient interaction.
o Common misconception: Sterile technique is
required for all contact.
o Safety risk: Wasted resources and false sense of
safety; may lead to poor adherence to proper
standard precautions.
Nursing Process Linkage: Implementation
NCJMM Competencies: Generate Solutions, Take Action
Difficulty Level: Easy
