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 postoperative client on the surgical unit
becomes restless and says, “I cannot catch my breath.” The
nurse notes a respiratory rate of 28/min and an oxygen
saturation of 89% on room air.
Question stem: What is the nurse’s best first action?
Answer options:
A. Place the client in high Fowler position and apply oxygen per
protocol
B. Document the findings and reassess in 15 minutes
C. Notify the provider after completing the full head-to-toe
assessment
D. Encourage the client to use the incentive spirometer 10
times
Correct answer: A
Detailed rationale:
The client has airway/breathing compromise, which takes
priority in clinical judgment. High Fowler position improves
chest expansion, and oxygen supports tissue oxygenation while
the nurse continues focused assessment and activates further
help as needed. This reflects recognize cues → take action and
supports early intervention for deterioration.
,Incorrect option analysis:
• B: Incorrect because this delays intervention for a
potentially unstable breathing problem.
o Misconception: “Recheck later” is safer than
immediate action.
o Safety risk: Worsening hypoxemia and respiratory
failure.
• C: Incorrect because provider notification should not delay
immediate stabilization measures.
o Misconception: The nurse must finish all assessment
before acting.
o Safety risk: Delayed oxygenation support.
• D: Incorrect because incentive spirometry is helpful for
prevention, but not the first response to acute dyspnea
and desaturation.
o Misconception: All postoperative breathing problems
are treated the same.
o Safety risk: Failure to address acute oxygen deficit.
Nursing process linkage: Assessment / Implementation
NCJMM competencies: Recognize Cues, Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Physiological Adaptation
, Key learning objective: Prioritize immediate nursing actions for
acute respiratory deterioration.
2) MCQ
Clinical scenario: A unit council is revising the fall-prevention
protocol for older adults.
Question stem: Which source is the best evidence to guide the
updated protocol?
Answer options:
A. A coworker’s experience caring for a patient who fell
B. A current clinical practice guideline and systematic review
C. The routine practice used on the unit for the last 10 years
D. A single opinion article from a local newsletter
Correct answer: B
Detailed rationale:
Evidence-based practice relies on the best available research,
especially clinical practice guidelines and systematic reviews.
These sources synthesize the strongest evidence and support
safer, more consistent outcomes.
Incorrect option analysis:
• A: Incorrect because anecdotal experience is not strong
enough to guide unit policy.
o Misconception: Personal experience equals evidence.
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Clinical scenario: A postoperative client on the surgical unit
becomes restless and says, “I cannot catch my breath.” The
nurse notes a respiratory rate of 28/min and an oxygen
saturation of 89% on room air.
Question stem: What is the nurse’s best first action?
Answer options:
A. Place the client in high Fowler position and apply oxygen per
protocol
B. Document the findings and reassess in 15 minutes
C. Notify the provider after completing the full head-to-toe
assessment
D. Encourage the client to use the incentive spirometer 10
times
Correct answer: A
Detailed rationale:
The client has airway/breathing compromise, which takes
priority in clinical judgment. High Fowler position improves
chest expansion, and oxygen supports tissue oxygenation while
the nurse continues focused assessment and activates further
help as needed. This reflects recognize cues → take action and
supports early intervention for deterioration.
,Incorrect option analysis:
• B: Incorrect because this delays intervention for a
potentially unstable breathing problem.
o Misconception: “Recheck later” is safer than
immediate action.
o Safety risk: Worsening hypoxemia and respiratory
failure.
• C: Incorrect because provider notification should not delay
immediate stabilization measures.
o Misconception: The nurse must finish all assessment
before acting.
o Safety risk: Delayed oxygenation support.
• D: Incorrect because incentive spirometry is helpful for
prevention, but not the first response to acute dyspnea
and desaturation.
o Misconception: All postoperative breathing problems
are treated the same.
o Safety risk: Failure to address acute oxygen deficit.
Nursing process linkage: Assessment / Implementation
NCJMM competencies: Recognize Cues, Take Action
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Physiological Adaptation
, Key learning objective: Prioritize immediate nursing actions for
acute respiratory deterioration.
2) MCQ
Clinical scenario: A unit council is revising the fall-prevention
protocol for older adults.
Question stem: Which source is the best evidence to guide the
updated protocol?
Answer options:
A. A coworker’s experience caring for a patient who fell
B. A current clinical practice guideline and systematic review
C. The routine practice used on the unit for the last 10 years
D. A single opinion article from a local newsletter
Correct answer: B
Detailed rationale:
Evidence-based practice relies on the best available research,
especially clinical practice guidelines and systematic reviews.
These sources synthesize the strongest evidence and support
safer, more consistent outcomes.
Incorrect option analysis:
• A: Incorrect because anecdotal experience is not strong
enough to guide unit policy.
o Misconception: Personal experience equals evidence.
