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 newly admitted 78-year-old client with heart failure is
drowsy, has cool clammy skin, and has an oxygen saturation of
88% on room air. The nurse is completing the admission
assessment.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Complete the full history before intervening
B. Apply oxygen and reassess the client
C. Ask the family to stay outside the room
D. Document the findings in the admission note first
Correct Answer:
B. Apply oxygen and reassess the client
Detailed Rationale:
The client shows cues of possible hypoxemia and decreased
perfusion. The nurse must take immediate action to support
oxygenation, then reassess response. This reflects early
recognition of deterioration and action based on priority ABCs.
Incorrect Option Analysis:
, • A. Incorrect because delaying intervention for a full history
risks deterioration.
o Misconception: assessment always comes before
action.
o Safety risk: worsening hypoxia.
• C. Incorrect because family presence is not the urgent
issue.
o Misconception: removing distractions fixes instability.
o Safety risk: delays response.
• D. Incorrect because documentation follows intervention.
o Misconception: charting is a priority over stabilization.
o Safety risk: no immediate treatment.
Nursing Process Linkage:
Implementation
NCJMM Competencies:
Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
, Key Learning Objective:
Prioritize immediate nursing action for signs of compromised
oxygenation and perfusion.
2) SATA
Clinical Scenario:
A nurse is planning discharge teaching for an older adult who
will return home after abdominal surgery.
Question Stem:
Which nursing actions reflect patient-centered care? Select all
that apply.
Answer Options:
A. Ask the client what matters most to them during recovery
B. Use only the medical team’s preferred teaching schedule
C. Involve the client’s chosen support person in teaching
D. Adapt discharge instructions to the client’s literacy level
E. Give the same standard handout to every client
Correct Answers:
A, C, D
Detailed Rationale:
Patient-centered care respects values, preferences, support
systems, and individual learning needs. It increases adherence
and outcomes.
Incorrect Option Analysis:
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Clinical Scenario:
A newly admitted 78-year-old client with heart failure is
drowsy, has cool clammy skin, and has an oxygen saturation of
88% on room air. The nurse is completing the admission
assessment.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Complete the full history before intervening
B. Apply oxygen and reassess the client
C. Ask the family to stay outside the room
D. Document the findings in the admission note first
Correct Answer:
B. Apply oxygen and reassess the client
Detailed Rationale:
The client shows cues of possible hypoxemia and decreased
perfusion. The nurse must take immediate action to support
oxygenation, then reassess response. This reflects early
recognition of deterioration and action based on priority ABCs.
Incorrect Option Analysis:
, • A. Incorrect because delaying intervention for a full history
risks deterioration.
o Misconception: assessment always comes before
action.
o Safety risk: worsening hypoxia.
• C. Incorrect because family presence is not the urgent
issue.
o Misconception: removing distractions fixes instability.
o Safety risk: delays response.
• D. Incorrect because documentation follows intervention.
o Misconception: charting is a priority over stabilization.
o Safety risk: no immediate treatment.
Nursing Process Linkage:
Implementation
NCJMM Competencies:
Recognize Cues; Prioritize Hypotheses; Take Action
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
, Key Learning Objective:
Prioritize immediate nursing action for signs of compromised
oxygenation and perfusion.
2) SATA
Clinical Scenario:
A nurse is planning discharge teaching for an older adult who
will return home after abdominal surgery.
Question Stem:
Which nursing actions reflect patient-centered care? Select all
that apply.
Answer Options:
A. Ask the client what matters most to them during recovery
B. Use only the medical team’s preferred teaching schedule
C. Involve the client’s chosen support person in teaching
D. Adapt discharge instructions to the client’s literacy level
E. Give the same standard handout to every client
Correct Answers:
A, C, D
Detailed Rationale:
Patient-centered care respects values, preferences, support
systems, and individual learning needs. It increases adherence
and outcomes.
Incorrect Option Analysis:
