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 an adult admitted with community-
acquired pneumonia. The patient’s respiratory rate is 30/min,
SpO₂ is 88% on room air, accessory muscles are in use, and the
patient can speak only in 2-word phrases.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Complete a full head-to-toe assessment first
B. Apply oxygen and raise the head of the bed
C. Obtain a sputum specimen before any intervention
D. Notify the provider about the elevated temperature
Correct Answer:
B
Detailed Rationale:
This patient shows signs of acute respiratory compromise.
According to clinical judgment and ABC prioritization, the nurse
must support oxygenation immediately. Elevating the head of
the bed improves lung expansion, and oxygen increases tissue
oxygen delivery while further assessment is completed.
Incorrect Option Analysis:
, • A. Incorrect: A full assessment delays airway/breathing
support. Misconception: assessment always comes before
action. Risk: worsening hypoxemia and respiratory failure.
• C. Incorrect: A specimen can be collected later.
Misconception: diagnostic tasks are more urgent than
stabilizing the patient. Risk: delay in oxygenation.
• D. Incorrect: Fever matters, but it is not the immediate
priority. Misconception: all abnormal findings require the
same urgency. Risk: missing a time-sensitive respiratory
decline.
Nursing Process Linkage: Implementation
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Prioritize Hypotheses, Take Action
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Prioritize immediate interventions for
impaired oxygenation.
2) MCQ
Clinical Scenario:
During shift handoff, the off-going nurse states that a patient is
“not allergic to penicillin anymore,” but the chart still lists a
severe penicillin allergy. The oncoming nurse is preparing the
scheduled antibiotic.
, Question Stem:
What is the best action?
Answer Options:
A. Give the antibiotic and monitor closely
B. Hold the medication, verify the allergy history, and clarify the
order using SBAR
C. Ask the UAP to recheck the allergy band
D. Document the discrepancy after the medication is given
Correct Answer:
B
Detailed Rationale:
Medication safety begins with verifying critical information
before administration. A severe documented allergy requires
immediate clarification. Using SBAR supports closed-loop
communication and helps prevent anaphylaxis or other adverse
drug events.
Incorrect Option Analysis:
• A. Incorrect: This is unsafe when a severe allergy is
documented. Misconception: “monitoring closely” can
substitute for verification. Risk: life-threatening allergic
reaction.
• C. Incorrect: UAPs do not verify allergy histories or resolve
medication-order discrepancies. Misconception: task
delegation can replace nursing judgment. Risk: incomplete
safety check.
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 an adult admitted with community-
acquired pneumonia. The patient’s respiratory rate is 30/min,
SpO₂ is 88% on room air, accessory muscles are in use, and the
patient can speak only in 2-word phrases.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Complete a full head-to-toe assessment first
B. Apply oxygen and raise the head of the bed
C. Obtain a sputum specimen before any intervention
D. Notify the provider about the elevated temperature
Correct Answer:
B
Detailed Rationale:
This patient shows signs of acute respiratory compromise.
According to clinical judgment and ABC prioritization, the nurse
must support oxygenation immediately. Elevating the head of
the bed improves lung expansion, and oxygen increases tissue
oxygen delivery while further assessment is completed.
Incorrect Option Analysis:
, • A. Incorrect: A full assessment delays airway/breathing
support. Misconception: assessment always comes before
action. Risk: worsening hypoxemia and respiratory failure.
• C. Incorrect: A specimen can be collected later.
Misconception: diagnostic tasks are more urgent than
stabilizing the patient. Risk: delay in oxygenation.
• D. Incorrect: Fever matters, but it is not the immediate
priority. Misconception: all abnormal findings require the
same urgency. Risk: missing a time-sensitive respiratory
decline.
Nursing Process Linkage: Implementation
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Prioritize Hypotheses, Take Action
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Prioritize immediate interventions for
impaired oxygenation.
2) MCQ
Clinical Scenario:
During shift handoff, the off-going nurse states that a patient is
“not allergic to penicillin anymore,” but the chart still lists a
severe penicillin allergy. The oncoming nurse is preparing the
scheduled antibiotic.
, Question Stem:
What is the best action?
Answer Options:
A. Give the antibiotic and monitor closely
B. Hold the medication, verify the allergy history, and clarify the
order using SBAR
C. Ask the UAP to recheck the allergy band
D. Document the discrepancy after the medication is given
Correct Answer:
B
Detailed Rationale:
Medication safety begins with verifying critical information
before administration. A severe documented allergy requires
immediate clarification. Using SBAR supports closed-loop
communication and helps prevent anaphylaxis or other adverse
drug events.
Incorrect Option Analysis:
• A. Incorrect: This is unsafe when a severe allergy is
documented. Misconception: “monitoring closely” can
substitute for verification. Risk: life-threatening allergic
reaction.
• C. Incorrect: UAPs do not verify allergy histories or resolve
medication-order discrepancies. Misconception: task
delegation can replace nursing judgment. Risk: incomplete
safety check.
