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 Judgment
Clinical Scenario:
A patient is 2 hours post-op after abdominal surgery. The nurse
notes that the patient is difficult to arouse, has shallow
respirations at 10/min, and oxygen saturation of 90% on room
air. The patient received IV morphine 45 minutes ago.
Question Stem:
What is the nurse’s best first action?
Answer Options:
A. Encourage the patient to take slow deep breaths and
reassess in 30 minutes
B. Administer naloxone immediately without further
assessment
C. Assess airway and breathing, apply oxygen per protocol, and
stimulate the patient while preparing to notify the provider
D. Offer oral fluids and assist the patient to ambulate
Correct Answer:
C
Detailed Rationale:
This patient shows early signs of opioid-induced respiratory
depression. Airway and breathing take priority. The nurse
should assess respiratory status, support oxygenation, and
stimulate the patient while preparing escalation. This is
consistent with clinical judgment and patient safety.
,Incorrect Option Analysis:
• A: Incorrect because waiting delays intervention for a
breathing problem.
o Misconception: Mild drowsiness is acceptable after
opioids.
o Risk: Worsening hypoventilation and hypoxemia.
• B: Incorrect because naloxone is not the first step without
assessment and supportive measures.
o Misconception: Reversal medication always comes
before assessment.
o Risk: Missing the need for immediate oxygen support
and monitoring.
• D: Incorrect because ambulation and fluids are unsafe with
possible respiratory depression.
o Misconception: Movement will “wake the patient up”
safely.
o Risk: Falls and delayed recognition of deterioration.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues; Take Action
Difficulty Level:
Difficult
, Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify and respond to early postoperative respiratory
compromise using priority-based nursing judgment.
2) MCQ — Nursing Process
Clinical Scenario:
A nurse is caring for a patient with incisional pain after surgery.
After giving analgesia, the nurse reassesses the patient 30
minutes later.
Question Stem:
Which finding best reflects the evaluation step of the nursing
process?
Answer Options:
A. The patient rates pain as 3/10, down from 8/10 before
medication
B. The nurse identifies acute pain related to surgery
C. The nurse selects nonpharmacologic comfort measures
D. The nurse records the initial pain assessment
Correct Answer:
A
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ — Clinical Judgment
Clinical Scenario:
A patient is 2 hours post-op after abdominal surgery. The nurse
notes that the patient is difficult to arouse, has shallow
respirations at 10/min, and oxygen saturation of 90% on room
air. The patient received IV morphine 45 minutes ago.
Question Stem:
What is the nurse’s best first action?
Answer Options:
A. Encourage the patient to take slow deep breaths and
reassess in 30 minutes
B. Administer naloxone immediately without further
assessment
C. Assess airway and breathing, apply oxygen per protocol, and
stimulate the patient while preparing to notify the provider
D. Offer oral fluids and assist the patient to ambulate
Correct Answer:
C
Detailed Rationale:
This patient shows early signs of opioid-induced respiratory
depression. Airway and breathing take priority. The nurse
should assess respiratory status, support oxygenation, and
stimulate the patient while preparing escalation. This is
consistent with clinical judgment and patient safety.
,Incorrect Option Analysis:
• A: Incorrect because waiting delays intervention for a
breathing problem.
o Misconception: Mild drowsiness is acceptable after
opioids.
o Risk: Worsening hypoventilation and hypoxemia.
• B: Incorrect because naloxone is not the first step without
assessment and supportive measures.
o Misconception: Reversal medication always comes
before assessment.
o Risk: Missing the need for immediate oxygen support
and monitoring.
• D: Incorrect because ambulation and fluids are unsafe with
possible respiratory depression.
o Misconception: Movement will “wake the patient up”
safely.
o Risk: Falls and delayed recognition of deterioration.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues; Take Action
Difficulty Level:
Difficult
, Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify and respond to early postoperative respiratory
compromise using priority-based nursing judgment.
2) MCQ — Nursing Process
Clinical Scenario:
A nurse is caring for a patient with incisional pain after surgery.
After giving analgesia, the nurse reassesses the patient 30
minutes later.
Question Stem:
Which finding best reflects the evaluation step of the nursing
process?
Answer Options:
A. The patient rates pain as 3/10, down from 8/10 before
medication
B. The nurse identifies acute pain related to surgery
C. The nurse selects nonpharmacologic comfort measures
D. The nurse records the initial pain assessment
Correct Answer:
A
