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 new graduate nurse is caring for a patient
with shortness of breath after walking to the bathroom. The
patient is sitting upright, respirations are 28/min, and oxygen
saturation is 91% on room air.
Question Stem: Which nursing action best reflects the first step
of clinical judgment?
Answer Options:
A. Document the findings in the chart
B. Compare the findings with the provider’s last note
C. Assess the patient’s lung sounds and work of breathing
D. Request a respiratory therapy consult
Correct Answer: C
Detailed Rationale:
Clinical judgment begins with recognizing and assessing cues.
The nurse must gather more data by assessing lung sounds, use
of accessory muscles, and overall respiratory effort. The current
findings suggest possible respiratory compromise, but the
nurse should not jump to documentation or consultation
before completing focused assessment.
Incorrect Option Analysis:
• A: Incorrect. Documentation matters, but not before
assessment when the patient may be deteriorating.
, o Misconception: Charting first is safe.
o Risk: Delays identification of hypoxia.
• B: Incorrect. Prior notes may provide context, but
immediate bedside assessment is more urgent.
o Misconception: Comparing with prior data replaces
assessment.
o Risk: Misses worsening respiratory status.
• D: Incorrect. Collaboration may be needed later, but first
the nurse must assess.
o Misconception: Calling another discipline is the first
nursing response.
o Risk: Delayed recognition of deterioration.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues; Analyze Cues
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify assessment as the first step in
clinical judgment when a patient shows possible deterioration.
2) MCQ
Clinical Scenario: A nurse is teaching a patient with heart
failure how to monitor daily weights at home.
, Question Stem: Which patient statement indicates effective
understanding of a patient-centered teaching plan?
Answer Options:
A. “I will weigh myself once a week in the evening.”
B. “I will weigh myself every morning after urinating and before
breakfast.”
C. “I will weigh myself only if I notice swelling in my legs.”
D. “I will stop taking my diuretic if my weight decreases.”
Correct Answer: B
Detailed Rationale:
Daily weights should be obtained every morning after voiding
and before eating, using the same scale and clothing. This
creates consistent data for detecting fluid retention early,
which is central to self-management and prevention of
worsening heart failure.
Incorrect Option Analysis:
• A: Incorrect. Weekly weights are too infrequent to detect
early fluid changes.
o Misconception: Any routine weight check is enough.
o Risk: Delayed recognition of fluid overload.
• C: Incorrect. Waiting for edema misses early signs of
decompensation.
o Misconception: Visible swelling is the first sign.
o Risk: Late intervention.
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Clinical Scenario: A new graduate nurse is caring for a patient
with shortness of breath after walking to the bathroom. The
patient is sitting upright, respirations are 28/min, and oxygen
saturation is 91% on room air.
Question Stem: Which nursing action best reflects the first step
of clinical judgment?
Answer Options:
A. Document the findings in the chart
B. Compare the findings with the provider’s last note
C. Assess the patient’s lung sounds and work of breathing
D. Request a respiratory therapy consult
Correct Answer: C
Detailed Rationale:
Clinical judgment begins with recognizing and assessing cues.
The nurse must gather more data by assessing lung sounds, use
of accessory muscles, and overall respiratory effort. The current
findings suggest possible respiratory compromise, but the
nurse should not jump to documentation or consultation
before completing focused assessment.
Incorrect Option Analysis:
• A: Incorrect. Documentation matters, but not before
assessment when the patient may be deteriorating.
, o Misconception: Charting first is safe.
o Risk: Delays identification of hypoxia.
• B: Incorrect. Prior notes may provide context, but
immediate bedside assessment is more urgent.
o Misconception: Comparing with prior data replaces
assessment.
o Risk: Misses worsening respiratory status.
• D: Incorrect. Collaboration may be needed later, but first
the nurse must assess.
o Misconception: Calling another discipline is the first
nursing response.
o Risk: Delayed recognition of deterioration.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues; Analyze Cues
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify assessment as the first step in
clinical judgment when a patient shows possible deterioration.
2) MCQ
Clinical Scenario: A nurse is teaching a patient with heart
failure how to monitor daily weights at home.
, Question Stem: Which patient statement indicates effective
understanding of a patient-centered teaching plan?
Answer Options:
A. “I will weigh myself once a week in the evening.”
B. “I will weigh myself every morning after urinating and before
breakfast.”
C. “I will weigh myself only if I notice swelling in my legs.”
D. “I will stop taking my diuretic if my weight decreases.”
Correct Answer: B
Detailed Rationale:
Daily weights should be obtained every morning after voiding
and before eating, using the same scale and clothing. This
creates consistent data for detecting fluid retention early,
which is central to self-management and prevention of
worsening heart failure.
Incorrect Option Analysis:
• A: Incorrect. Weekly weights are too infrequent to detect
early fluid changes.
o Misconception: Any routine weight check is enough.
o Risk: Delayed recognition of fluid overload.
• C: Incorrect. Waiting for edema misses early signs of
decompensation.
o Misconception: Visible swelling is the first sign.
o Risk: Late intervention.
