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 postoperative patient on the medical-
surgical unit. During the assessment, the patient becomes
drowsy, the respiratory rate drops from 18/min to 10/min, and
oxygen saturation decreases from 96% to 89% on room air.
Question Stem:
What is the nurse’s best first action?
Answer Options:
A. Document the change and reassess in 15 minutes
B. Notify the provider immediately
C. Assess airway, breathing, and oxygenation right away
D. Place the patient in high Fowler’s position after calling the
family
Correct Answer:
C. Assess airway, breathing, and oxygenation right away
Detailed Rationale:
The nurse must first recognize cues suggesting possible
respiratory depression and use the ABC priority framework.
Immediate assessment of airway and breathing is the safest
first step because the patient may need oxygen, stimulation, or
escalation of care. Clinical judgment begins with validating the
patient’s actual condition before selecting an intervention.
Incorrect Option Analysis:
, • A. Incorrect — Delaying action risks worsening hypoxemia.
o Misconception: “Watch and wait” is appropriate
when the patient looks sleepy.
o Safety risk: Respiratory arrest or cardiac
deterioration.
• B. Incorrect — Provider notification may be needed, but
assessment comes first.
o Misconception: Calling is always the first action when
a change occurs.
o Safety risk: Incomplete report delays urgent care.
• D. Incorrect — Positioning may help, but it is not the first
priority over assessing breathing.
o Misconception: Comfort measures should precede
assessment.
o Safety risk: Missed early respiratory compromise.
Nursing Process Linkage:
Assessment
NCJMM Competencies:
Recognize Cues; Analyze Cues; Take Action
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
, NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify the nurse’s first action when a patient shows acute
deterioration in oxygenation and respiratory status.
2) SATA
Clinical Scenario:
A new graduate nurse is reviewing evidence-based nursing
practice with the preceptor.
Question Stem:
Which nursing actions reflect evidence-based practice? Select
all that apply.
Answer Options:
A. Using a current clinical practice guideline to guide care
B. Combining research evidence with patient values and
preferences
C. Choosing an intervention because it was used that way on
the previous unit
D. Evaluating outcomes after an intervention is implemented
E. Checking the credibility and relevance of the evidence before
applying it
Correct Answer:
A, B, D, E
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 postoperative patient on the medical-
surgical unit. During the assessment, the patient becomes
drowsy, the respiratory rate drops from 18/min to 10/min, and
oxygen saturation decreases from 96% to 89% on room air.
Question Stem:
What is the nurse’s best first action?
Answer Options:
A. Document the change and reassess in 15 minutes
B. Notify the provider immediately
C. Assess airway, breathing, and oxygenation right away
D. Place the patient in high Fowler’s position after calling the
family
Correct Answer:
C. Assess airway, breathing, and oxygenation right away
Detailed Rationale:
The nurse must first recognize cues suggesting possible
respiratory depression and use the ABC priority framework.
Immediate assessment of airway and breathing is the safest
first step because the patient may need oxygen, stimulation, or
escalation of care. Clinical judgment begins with validating the
patient’s actual condition before selecting an intervention.
Incorrect Option Analysis:
, • A. Incorrect — Delaying action risks worsening hypoxemia.
o Misconception: “Watch and wait” is appropriate
when the patient looks sleepy.
o Safety risk: Respiratory arrest or cardiac
deterioration.
• B. Incorrect — Provider notification may be needed, but
assessment comes first.
o Misconception: Calling is always the first action when
a change occurs.
o Safety risk: Incomplete report delays urgent care.
• D. Incorrect — Positioning may help, but it is not the first
priority over assessing breathing.
o Misconception: Comfort measures should precede
assessment.
o Safety risk: Missed early respiratory compromise.
Nursing Process Linkage:
Assessment
NCJMM Competencies:
Recognize Cues; Analyze Cues; Take Action
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
, NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify the nurse’s first action when a patient shows acute
deterioration in oxygenation and respiratory status.
2) SATA
Clinical Scenario:
A new graduate nurse is reviewing evidence-based nursing
practice with the preceptor.
Question Stem:
Which nursing actions reflect evidence-based practice? Select
all that apply.
Answer Options:
A. Using a current clinical practice guideline to guide care
B. Combining research evidence with patient values and
preferences
C. Choosing an intervention because it was used that way on
the previous unit
D. Evaluating outcomes after an intervention is implemented
E. Checking the credibility and relevance of the evidence before
applying it
Correct Answer:
A, B, D, E
