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 patient on a medical-surgical unit says, “I suddenly feel short
of breath,” after walking from the bathroom to the bed. The
nurse notes restlessness and a respiratory rate of 28/min.
Question Stem:
What should the nurse do first?
Answer Options:
A. Obtain a focused respiratory assessment and pulse oximetry
B. Document the complaint and recheck in 15 minutes
C. Notify the provider immediately without assessing further
D. Offer sips of water and encourage slow breathing
Correct Answer:
A
Detailed Rationale:
The nurse’s first action is to recognize cues and perform a
focused assessment of breathing and oxygenation. The patient
may be deteriorating, but safe clinical judgment begins with
immediate assessment of airway, breathing, and oxygen
saturation before escalating further.
Incorrect Option Analysis:
• B: Delays assessment and risks missing acute hypoxemia.
, o Misconception: Symptoms can be watched first when
the patient is unstable.
o Safety Risk: Missed respiratory compromise.
• C: Premature escalation without current assessment data.
o Misconception: Calling the provider is always the first
step.
o Safety Risk: Incomplete communication and slower
intervention.
• D: Does not address the likely physiologic problem.
o Misconception: Anxiety-style interventions are
enough for dyspnea.
o Safety Risk: Worsening respiratory distress.
Nursing Process Linkage:
Assessment
NCJMM Competencies:
Recognize Cues; Take Action
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
, Key Learning Objective:
Prioritize the first nursing action when a patient shows an acute
change in respiratory status.
2. SATA
Clinical Scenario:
A unit is revising its wound-care policy using recent literature
and patient feedback.
Question Stem:
Which actions reflect evidence-based nursing care? Select all
that apply.
Answer Options:
A. Use current clinical guidelines
B. Combine research evidence with clinical expertise
C. Include patient values and preferences
D. Continue the old practice because it has “always worked”
E. Evaluate patient outcomes after implementing the change
Correct Answers:
A, B, C, E
Detailed Rationale:
Evidence-based nursing care integrates best available
evidence, clinical judgment, and patient preferences. The
nurse should also evaluate whether the practice change
improves outcomes.
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 patient on a medical-surgical unit says, “I suddenly feel short
of breath,” after walking from the bathroom to the bed. The
nurse notes restlessness and a respiratory rate of 28/min.
Question Stem:
What should the nurse do first?
Answer Options:
A. Obtain a focused respiratory assessment and pulse oximetry
B. Document the complaint and recheck in 15 minutes
C. Notify the provider immediately without assessing further
D. Offer sips of water and encourage slow breathing
Correct Answer:
A
Detailed Rationale:
The nurse’s first action is to recognize cues and perform a
focused assessment of breathing and oxygenation. The patient
may be deteriorating, but safe clinical judgment begins with
immediate assessment of airway, breathing, and oxygen
saturation before escalating further.
Incorrect Option Analysis:
• B: Delays assessment and risks missing acute hypoxemia.
, o Misconception: Symptoms can be watched first when
the patient is unstable.
o Safety Risk: Missed respiratory compromise.
• C: Premature escalation without current assessment data.
o Misconception: Calling the provider is always the first
step.
o Safety Risk: Incomplete communication and slower
intervention.
• D: Does not address the likely physiologic problem.
o Misconception: Anxiety-style interventions are
enough for dyspnea.
o Safety Risk: Worsening respiratory distress.
Nursing Process Linkage:
Assessment
NCJMM Competencies:
Recognize Cues; Take Action
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
, Key Learning Objective:
Prioritize the first nursing action when a patient shows an acute
change in respiratory status.
2. SATA
Clinical Scenario:
A unit is revising its wound-care policy using recent literature
and patient feedback.
Question Stem:
Which actions reflect evidence-based nursing care? Select all
that apply.
Answer Options:
A. Use current clinical guidelines
B. Combine research evidence with clinical expertise
C. Include patient values and preferences
D. Continue the old practice because it has “always worked”
E. Evaluate patient outcomes after implementing the change
Correct Answers:
A, B, C, E
Detailed Rationale:
Evidence-based nursing care integrates best available
evidence, clinical judgment, and patient preferences. The
nurse should also evaluate whether the practice change
improves outcomes.
