Davis Advantage for Medical-
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Clinical Scenario:
A nurse is caring for a 72-year-old patient who is 8 hours post-
op after abdominal surgery. The patient says, “I just do not feel
right,” but the vital signs are still within the expected range.
The nurse notices the respiratory rate has increased from 16 to
22/min, the heart rate has risen from 84 to 104/min, and the
patient is more anxious than earlier.
Question Stem:
Which nursing action best demonstrates clinical judgment?
Answer Options:
A. Document the assessment as normal because all values are
still within reference range
B. Reassess the patient and compare current findings with
baseline trends
C. Wait until the next scheduled vital sign check to avoid
unnecessary alarm
D. Ask the family whether the patient usually becomes anxious
after surgery
Correct Answer:
B
Detailed Rationale:
Clinical judgment begins with recognizing subtle cues and
comparing them with baseline data. The rising respiratory and
,heart rates plus new anxiety may be early indicators of
deterioration even if individual values are not yet critical.
Reassessment and trend comparison help the nurse identify
change early and act before instability progresses.
Incorrect Option Analysis:
• A. Incorrect. Normal-looking isolated values can hide early
deterioration.
o Common misconception: “If the numbers are in
range, the patient is stable.”
o Safety risk: Missed early warning signs.
• C. Incorrect. Waiting delays evaluation of a possible
change in condition.
o Common misconception: “Only abnormal vitals need
action.”
o Safety risk: Delayed intervention.
• D. Incorrect. Family input may help background
understanding, but it does not replace direct
reassessment.
o Common misconception: “Behavioral changes are
usually nonclinical.”
o Safety risk: Underestimating acute deterioration.
Nursing Process Linkage:
Assessment
, Clinical Judgment Competency (NCJMM):
Recognize Cues, Analyze Cues
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Reduction of Risk Potential
Key Learning Objective:
Identify early changes in condition and use baseline comparison
to support clinical judgment.
2) MCQ
Clinical Scenario:
A patient admitted for chronic heart failure speaks limited
English and nods during teaching. The patient’s adult daughter
says, “I will translate everything for her.”
Question Stem:
What is the best nursing action?
Answer Options:
A. Use the daughter as the interpreter because family
involvement is culturally appropriate
B. Speak more slowly and use simpler English without an
interpreter
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Clinical Scenario:
A nurse is caring for a 72-year-old patient who is 8 hours post-
op after abdominal surgery. The patient says, “I just do not feel
right,” but the vital signs are still within the expected range.
The nurse notices the respiratory rate has increased from 16 to
22/min, the heart rate has risen from 84 to 104/min, and the
patient is more anxious than earlier.
Question Stem:
Which nursing action best demonstrates clinical judgment?
Answer Options:
A. Document the assessment as normal because all values are
still within reference range
B. Reassess the patient and compare current findings with
baseline trends
C. Wait until the next scheduled vital sign check to avoid
unnecessary alarm
D. Ask the family whether the patient usually becomes anxious
after surgery
Correct Answer:
B
Detailed Rationale:
Clinical judgment begins with recognizing subtle cues and
comparing them with baseline data. The rising respiratory and
,heart rates plus new anxiety may be early indicators of
deterioration even if individual values are not yet critical.
Reassessment and trend comparison help the nurse identify
change early and act before instability progresses.
Incorrect Option Analysis:
• A. Incorrect. Normal-looking isolated values can hide early
deterioration.
o Common misconception: “If the numbers are in
range, the patient is stable.”
o Safety risk: Missed early warning signs.
• C. Incorrect. Waiting delays evaluation of a possible
change in condition.
o Common misconception: “Only abnormal vitals need
action.”
o Safety risk: Delayed intervention.
• D. Incorrect. Family input may help background
understanding, but it does not replace direct
reassessment.
o Common misconception: “Behavioral changes are
usually nonclinical.”
o Safety risk: Underestimating acute deterioration.
Nursing Process Linkage:
Assessment
, Clinical Judgment Competency (NCJMM):
Recognize Cues, Analyze Cues
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Reduction of Risk Potential
Key Learning Objective:
Identify early changes in condition and use baseline comparison
to support clinical judgment.
2) MCQ
Clinical Scenario:
A patient admitted for chronic heart failure speaks limited
English and nods during teaching. The patient’s adult daughter
says, “I will translate everything for her.”
Question Stem:
What is the best nursing action?
Answer Options:
A. Use the daughter as the interpreter because family
involvement is culturally appropriate
B. Speak more slowly and use simpler English without an
interpreter
