Davis Advantage for Medical-
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• PublisherPublished by F.A.
Davis Copyright© 2024
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Clinical Scenario:
A nurse is caring for a newly admitted adult medical-surgical
patient who says, “I do not feel right,” and is pale, slightly
diaphoretic, and holding the side of the abdomen.
Question Stem:
What is the nurse’s best first action?
Answer Options:
A. Administer the prescribed PRN analgesic.
B. Gather focused assessment data, including vital signs and
pain characteristics.
C. Notify the provider immediately with a report of abdominal
pain.
D. Reassure the patient and return in 30 minutes.
Correct Answer:
B. Gather focused assessment data, including vital signs and
pain characteristics.
Detailed Rationale:
Clinical judgment begins with recognize cues and assessment.
The patient has nonspecific but concerning cues that require
focused data collection before action. Vital signs, pain location,
onset, severity, and associated symptoms help the nurse
determine urgency and next steps.
Incorrect Option Analysis:
, • A: Incorrect because pain medication should not be given
before assessing the cause and severity.
Misconception: “Pain equals medication first.”
Safety risk: May mask worsening abdominal pathology.
• C: Incorrect because provider notification should be based
on completed assessment data unless the patient is
unstable.
Misconception: Calling the provider is always the first
step.
Safety risk: Incomplete communication can delay
appropriate intervention.
• D: Incorrect because the cues may indicate deterioration
and require immediate follow-up.
Misconception: Symptoms will resolve spontaneously.
Safety risk: Delayed recognition of a potentially serious
condition.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues; Analyze Cues
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify the nurse’s first action when
new concerning cues are identified.
2) MCQ
, Clinical Scenario:
After teaching a patient how to use an incentive spirometer,
the nurse asks the patient to demonstrate the technique. The
patient correctly performs the steps and states, “I will use it
every hour while I am awake.”
Question Stem:
Which step of the nursing process is this?
Answer Options:
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Correct Answer:
D. Evaluation
Detailed Rationale:
Evaluation determines whether the teaching was effective and
whether the desired outcome was achieved. Return
demonstration and verbalization of the plan show that the
outcome was met.
Incorrect Option Analysis:
• A: Incorrect because assessment occurs before teaching,
not after demonstration.
Misconception: Any patient interaction is assessment.
Safety risk: Failure to distinguish assessment from
evaluation can weaken care planning.
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• PublisherPublished by F.A.
Davis Copyright© 2024
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Clinical Scenario:
A nurse is caring for a newly admitted adult medical-surgical
patient who says, “I do not feel right,” and is pale, slightly
diaphoretic, and holding the side of the abdomen.
Question Stem:
What is the nurse’s best first action?
Answer Options:
A. Administer the prescribed PRN analgesic.
B. Gather focused assessment data, including vital signs and
pain characteristics.
C. Notify the provider immediately with a report of abdominal
pain.
D. Reassure the patient and return in 30 minutes.
Correct Answer:
B. Gather focused assessment data, including vital signs and
pain characteristics.
Detailed Rationale:
Clinical judgment begins with recognize cues and assessment.
The patient has nonspecific but concerning cues that require
focused data collection before action. Vital signs, pain location,
onset, severity, and associated symptoms help the nurse
determine urgency and next steps.
Incorrect Option Analysis:
, • A: Incorrect because pain medication should not be given
before assessing the cause and severity.
Misconception: “Pain equals medication first.”
Safety risk: May mask worsening abdominal pathology.
• C: Incorrect because provider notification should be based
on completed assessment data unless the patient is
unstable.
Misconception: Calling the provider is always the first
step.
Safety risk: Incomplete communication can delay
appropriate intervention.
• D: Incorrect because the cues may indicate deterioration
and require immediate follow-up.
Misconception: Symptoms will resolve spontaneously.
Safety risk: Delayed recognition of a potentially serious
condition.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues; Analyze Cues
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify the nurse’s first action when
new concerning cues are identified.
2) MCQ
, Clinical Scenario:
After teaching a patient how to use an incentive spirometer,
the nurse asks the patient to demonstrate the technique. The
patient correctly performs the steps and states, “I will use it
every hour while I am awake.”
Question Stem:
Which step of the nursing process is this?
Answer Options:
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Correct Answer:
D. Evaluation
Detailed Rationale:
Evaluation determines whether the teaching was effective and
whether the desired outcome was achieved. Return
demonstration and verbalization of the plan show that the
outcome was met.
Incorrect Option Analysis:
• A: Incorrect because assessment occurs before teaching,
not after demonstration.
Misconception: Any patient interaction is assessment.
Safety risk: Failure to distinguish assessment from
evaluation can weaken care planning.
