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 79-year-old postoperative patient received IV morphine 30
minutes ago. The nurse finds the patient difficult to arouse,
with respirations of 8/min and SpO₂ of 89% on room air.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Document the findings and reassess in 30 minutes.
B. Encourage the patient to ambulate to improve ventilation.
C. Assess airway, breathing, and oxygen saturation
immediately.
D. Offer oral fluids and reassess the pain score.
Correct answer:
C. Assess airway, breathing, and oxygen saturation
immediately.
Detailed rationale:
The patient shows signs of opioid-induced respiratory
depression, which is an immediate threat to oxygenation and
safety. The nurse must act first on airway and breathing, then
implement protocol-based interventions such as stimulation,
oxygen, or naloxone as ordered. This reflects early recognition
of deterioration and prioritization of physiologic stability.
,Incorrect option analysis:
• A: Incorrect because it delays intervention. Common
misconception: “I can monitor and see if it improves.”
Safety risk: worsening hypoxemia and respiratory arrest.
• B: Incorrect because ambulation is unsafe for a drowsy,
hypoxemic patient. Misconception: movement always
improves ventilation. Risk: fall and further compromise.
• D: Incorrect because fluids do not address respiratory
depression. Misconception: reassessing pain first is always
priority. Risk: delayed rescue action.
Nursing process linkage: Assessment
NCJMM competencies: Recognize Cues, Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Physiological Adaptation
Key learning objective: Identify and respond to acute
respiratory compromise after opioid administration.
2. MCQ
Clinical scenario:
A patient newly diagnosed with heart failure says, “I am
worried I cannot afford all these medications, and I care for my
grandson after school.”
, Question stem:
Which nursing response best reflects patient-centered care?
Answer options:
A. “The medications are important, so you will need to make
them work.”
B. “Let me give you the standard discharge teaching packet
first.”
C. “Let’s talk about your concerns and involve case
management in the plan.”
D. “We can discuss your schedule only after discharge.”
Correct answer:
C. “Let’s talk about your concerns and involve case
management in the plan.”
Detailed rationale:
Patient-centered care incorporates the patient’s goals, barriers,
family responsibilities, and resources into the plan of care. This
response supports shared decision-making, care coordination,
and realistic discharge planning.
Incorrect option analysis:
• A: Incorrect because it dismisses the patient’s barriers.
Misconception: compliance is more important than
collaboration. Risk: poor adherence and readmission.
• B: Incorrect because generic education is not
individualized. Risk: teaching that does not fit the patient’s
needs or circumstances.
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 79-year-old postoperative patient received IV morphine 30
minutes ago. The nurse finds the patient difficult to arouse,
with respirations of 8/min and SpO₂ of 89% on room air.
Question stem:
What is the nurse’s priority action?
Answer options:
A. Document the findings and reassess in 30 minutes.
B. Encourage the patient to ambulate to improve ventilation.
C. Assess airway, breathing, and oxygen saturation
immediately.
D. Offer oral fluids and reassess the pain score.
Correct answer:
C. Assess airway, breathing, and oxygen saturation
immediately.
Detailed rationale:
The patient shows signs of opioid-induced respiratory
depression, which is an immediate threat to oxygenation and
safety. The nurse must act first on airway and breathing, then
implement protocol-based interventions such as stimulation,
oxygen, or naloxone as ordered. This reflects early recognition
of deterioration and prioritization of physiologic stability.
,Incorrect option analysis:
• A: Incorrect because it delays intervention. Common
misconception: “I can monitor and see if it improves.”
Safety risk: worsening hypoxemia and respiratory arrest.
• B: Incorrect because ambulation is unsafe for a drowsy,
hypoxemic patient. Misconception: movement always
improves ventilation. Risk: fall and further compromise.
• D: Incorrect because fluids do not address respiratory
depression. Misconception: reassessing pain first is always
priority. Risk: delayed rescue action.
Nursing process linkage: Assessment
NCJMM competencies: Recognize Cues, Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Physiological Adaptation
Key learning objective: Identify and respond to acute
respiratory compromise after opioid administration.
2. MCQ
Clinical scenario:
A patient newly diagnosed with heart failure says, “I am
worried I cannot afford all these medications, and I care for my
grandson after school.”
, Question stem:
Which nursing response best reflects patient-centered care?
Answer options:
A. “The medications are important, so you will need to make
them work.”
B. “Let me give you the standard discharge teaching packet
first.”
C. “Let’s talk about your concerns and involve case
management in the plan.”
D. “We can discuss your schedule only after discharge.”
Correct answer:
C. “Let’s talk about your concerns and involve case
management in the plan.”
Detailed rationale:
Patient-centered care incorporates the patient’s goals, barriers,
family responsibilities, and resources into the plan of care. This
response supports shared decision-making, care coordination,
and realistic discharge planning.
Incorrect option analysis:
• A: Incorrect because it dismisses the patient’s barriers.
Misconception: compliance is more important than
collaboration. Risk: poor adherence and readmission.
• B: Incorrect because generic education is not
individualized. Risk: teaching that does not fit the patient’s
needs or circumstances.
