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. During
assessment, the nurse notes a respiratory rate of 28/min,
restlessness, and a decreasing oxygen saturation from 96% to
90%.
Question Stem:
Which action best reflects the nurse’s first step in clinical
judgment?
Answer Options:
A. Compare the finding with the patient’s baseline and collect
more cues
B. Document the findings and reassess in 1 hour
C. Teach the patient to use incentive spirometry
D. Administer the prescribed anti-anxiety medication
Correct Answer:
A. Compare the finding with the patient’s baseline and collect
more cues
Detailed Rationale:
Clinical judgment begins with recognizing and analyzing cues
before acting. A sudden change in respiratory status may signal
hypoxemia, atelectasis, opioid effect, or another complication.
The nurse should gather more assessment data, compare with
baseline, and determine the severity and likely cause before
,selecting an intervention. This supports safe, evidence-
informed practice.
Incorrect Option Analysis:
• B. Document the findings and reassess in 1 hour —
Incorrect. Delaying action can miss early deterioration. A
common misconception is that documentation replaces
assessment. Risk: delayed recognition of respiratory
failure.
• C. Teach the patient to use incentive spirometry —
Incorrect as the first step. Education may be appropriate
later, but the patient may already be deteriorating. Risk:
failure to intervene promptly.
• D. Administer the prescribed anti-anxiety medication —
Incorrect. Anxiety may be a symptom, not the cause.
Giving sedating medication could worsen respiratory
status. Risk: respiratory depression.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues, Analyze Cues
Difficulty: Moderate
Bloom’s Level: Analyze
NCLEX Client Needs: Reduction of Risk Potential
Key Learning Objective: Identify the first clinical judgment
action when a patient shows early signs of deterioration.
2) MCQ
, Clinical Scenario:
A unit is reviewing whether turning immobile patients every 2
hours reduces pressure injuries on the unit.
Question Stem:
Which source is the best evidence to guide this practice
change?
Answer Options:
A. A unit senior nurse’s experience with turning schedules
B. A systematic review or evidence-based clinical guideline
C. A single patient’s positive experience with turning
D. A textbook published 15 years ago
Correct Answer:
B. A systematic review or evidence-based clinical guideline
Detailed Rationale:
Evidence-based nursing care combines best research evidence,
clinical expertise, and patient preferences. Systematic reviews
and current guidelines synthesize multiple studies and are
stronger sources than opinion or isolated experiences when
revising practice.
Incorrect Option Analysis:
• A. A unit senior nurse’s experience — Incorrect.
Experience is valuable but not sufficient alone.
Misconception: “expert opinion equals evidence.” Risk:
inconsistent or outdated care.
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. During
assessment, the nurse notes a respiratory rate of 28/min,
restlessness, and a decreasing oxygen saturation from 96% to
90%.
Question Stem:
Which action best reflects the nurse’s first step in clinical
judgment?
Answer Options:
A. Compare the finding with the patient’s baseline and collect
more cues
B. Document the findings and reassess in 1 hour
C. Teach the patient to use incentive spirometry
D. Administer the prescribed anti-anxiety medication
Correct Answer:
A. Compare the finding with the patient’s baseline and collect
more cues
Detailed Rationale:
Clinical judgment begins with recognizing and analyzing cues
before acting. A sudden change in respiratory status may signal
hypoxemia, atelectasis, opioid effect, or another complication.
The nurse should gather more assessment data, compare with
baseline, and determine the severity and likely cause before
,selecting an intervention. This supports safe, evidence-
informed practice.
Incorrect Option Analysis:
• B. Document the findings and reassess in 1 hour —
Incorrect. Delaying action can miss early deterioration. A
common misconception is that documentation replaces
assessment. Risk: delayed recognition of respiratory
failure.
• C. Teach the patient to use incentive spirometry —
Incorrect as the first step. Education may be appropriate
later, but the patient may already be deteriorating. Risk:
failure to intervene promptly.
• D. Administer the prescribed anti-anxiety medication —
Incorrect. Anxiety may be a symptom, not the cause.
Giving sedating medication could worsen respiratory
status. Risk: respiratory depression.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues, Analyze Cues
Difficulty: Moderate
Bloom’s Level: Analyze
NCLEX Client Needs: Reduction of Risk Potential
Key Learning Objective: Identify the first clinical judgment
action when a patient shows early signs of deterioration.
2) MCQ
, Clinical Scenario:
A unit is reviewing whether turning immobile patients every 2
hours reduces pressure injuries on the unit.
Question Stem:
Which source is the best evidence to guide this practice
change?
Answer Options:
A. A unit senior nurse’s experience with turning schedules
B. A systematic review or evidence-based clinical guideline
C. A single patient’s positive experience with turning
D. A textbook published 15 years ago
Correct Answer:
B. A systematic review or evidence-based clinical guideline
Detailed Rationale:
Evidence-based nursing care combines best research evidence,
clinical expertise, and patient preferences. Systematic reviews
and current guidelines synthesize multiple studies and are
stronger sources than opinion or isolated experiences when
revising practice.
Incorrect Option Analysis:
• A. A unit senior nurse’s experience — Incorrect.
Experience is valuable but not sufficient alone.
Misconception: “expert opinion equals evidence.” Risk:
inconsistent or outdated care.
