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 newly licensed nurse is caring for a patient admitted with
shortness of breath and a possible pneumonia diagnosis. The
nurse notices the patient is anxious, speaking in short phrases,
and has an oxygen saturation of 89% on room air.
Question Stem:
Which action best reflects the first step in clinical judgment?
Answer Options:
A. Administer oxygen and reassess in 15 minutes.
B. Collect focused assessment data and compare it with the
patient’s baseline.
C. Notify the provider that the patient is deteriorating.
D. Document the oxygen saturation in the chart.
Correct Answer:
B. Collect focused assessment data and compare it with the
patient’s baseline.
Detailed Rationale:
Clinical judgment begins with recognizing and analyzing cues.
In this situation, the nurse must gather more information about
respiratory status, work of breathing, lung sounds, mental
status, and baseline oxygenation before deciding on
interventions. Comparing current findings with baseline helps
determine severity and urgency.
,Incorrect Option Analysis:
• A. Administer oxygen and reassess in 15 minutes.
o Why incorrect: Intervention comes after assessment
unless there is an immediate life-threatening
emergency.
o Common misconception: “Low oxygen means act
first without thinking.”
o Patient safety risk: Intervening without adequate
assessment may delay identification of worsening
respiratory failure or another cause.
• C. Notify the provider that the patient is deteriorating.
o Why incorrect: Escalation may be needed, but the
nurse must first assess to communicate accurate,
actionable data.
o Common misconception: Reporting is the same as
clinical judgment.
o Patient safety risk: Incomplete reporting can lead to
poor treatment decisions.
• D. Document the oxygen saturation in the chart.
o Why incorrect: Documentation is necessary but not
the immediate priority.
o Common misconception: Charting is a substitute for
action.
, o Patient safety risk: Delayed response to hypoxemia
may worsen outcomes.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Analyze Cues
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify the first step in clinical
judgment when a patient shows early signs of deterioration.
2) MCQ
Clinical Scenario:
A patient with hypertension is admitted for observation after
dizziness and a near-fall at home. The nurse is completing the
admission assessment.
Question Stem:
Which assessment finding is most important for the nurse to
obtain first?
Answer Options:
A. Preferred language for health teaching
B. Orthostatic blood pressure readings
C. Last bowel movement
D. Family history of hypertension
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 newly licensed nurse is caring for a patient admitted with
shortness of breath and a possible pneumonia diagnosis. The
nurse notices the patient is anxious, speaking in short phrases,
and has an oxygen saturation of 89% on room air.
Question Stem:
Which action best reflects the first step in clinical judgment?
Answer Options:
A. Administer oxygen and reassess in 15 minutes.
B. Collect focused assessment data and compare it with the
patient’s baseline.
C. Notify the provider that the patient is deteriorating.
D. Document the oxygen saturation in the chart.
Correct Answer:
B. Collect focused assessment data and compare it with the
patient’s baseline.
Detailed Rationale:
Clinical judgment begins with recognizing and analyzing cues.
In this situation, the nurse must gather more information about
respiratory status, work of breathing, lung sounds, mental
status, and baseline oxygenation before deciding on
interventions. Comparing current findings with baseline helps
determine severity and urgency.
,Incorrect Option Analysis:
• A. Administer oxygen and reassess in 15 minutes.
o Why incorrect: Intervention comes after assessment
unless there is an immediate life-threatening
emergency.
o Common misconception: “Low oxygen means act
first without thinking.”
o Patient safety risk: Intervening without adequate
assessment may delay identification of worsening
respiratory failure or another cause.
• C. Notify the provider that the patient is deteriorating.
o Why incorrect: Escalation may be needed, but the
nurse must first assess to communicate accurate,
actionable data.
o Common misconception: Reporting is the same as
clinical judgment.
o Patient safety risk: Incomplete reporting can lead to
poor treatment decisions.
• D. Document the oxygen saturation in the chart.
o Why incorrect: Documentation is necessary but not
the immediate priority.
o Common misconception: Charting is a substitute for
action.
, o Patient safety risk: Delayed response to hypoxemia
may worsen outcomes.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Analyze Cues
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify the first step in clinical
judgment when a patient shows early signs of deterioration.
2) MCQ
Clinical Scenario:
A patient with hypertension is admitted for observation after
dizziness and a near-fall at home. The nurse is completing the
admission assessment.
Question Stem:
Which assessment finding is most important for the nurse to
obtain first?
Answer Options:
A. Preferred language for health teaching
B. Orthostatic blood pressure readings
C. Last bowel movement
D. Family history of hypertension
