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 patient received IV morphine 20 minutes ago.
The nurse finds the patient difficult to arouse, with a
respiratory rate of 8/min and SpO₂ of 89% on room air.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Stimulate the patient and apply oxygen per protocol
B. Document the findings and reassess in 30 minutes
C. Administer the next dose of morphine when due
D. Ask the patient to rate the pain on a 0–10 scale
Correct Answer:
A
Detailed Rationale:
The patient shows opioid-related respiratory depression:
decreased level of consciousness, bradypnea, and hypoxemia.
The nurse must act immediately to support airway/breathing
and oxygenation. This reflects recognition of deterioration and
rapid intervention to prevent respiratory failure.
Incorrect Option Analysis:
• B: Incorrect. Delaying action risks worsening hypoxemia
and respiratory arrest.
, o Misconception: Thinking documentation comes
before rescue.
o Safety Risk: Failure to intervene can lead to cardiac
arrest.
• C: Incorrect. Additional opioid would further suppress
respirations.
o Misconception: Treating pain without assessing
physiologic stability.
o Safety Risk: Severe oversedation and arrest.
• D: Incorrect. Pain scoring is not the priority in an unstable
patient.
o Misconception: Pain assessment always comes first.
o Safety Risk: Delays life-saving respiratory support.
Nursing Process Linkage:
Implementation
NCJMM Competencies:
Recognize Cues; Analyze Cues; Take Action
Difficulty Level:
Difficult
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
, Key Learning Objective:
Identify immediate nursing actions for medication-related
respiratory compromise.
2. MCQ
Clinical Scenario:
A nurse is caring for a patient with limited mobility and pain
after abdominal surgery. The care plan includes a goal that the
patient will ambulate 50 feet by discharge.
Question Stem:
Which nursing process step is demonstrated by this goal?
Answer Options:
A. Assessment
B. Nursing diagnosis
C. Planning
D. Evaluation
Correct Answer:
C
Detailed Rationale:
Writing a measurable outcome is part of planning. The nurse is
establishing a patient-centered, realistic goal that can later be
evaluated. Nursing process steps must link assessment data to
goals and interventions.
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 postoperative patient received IV morphine 20 minutes ago.
The nurse finds the patient difficult to arouse, with a
respiratory rate of 8/min and SpO₂ of 89% on room air.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Stimulate the patient and apply oxygen per protocol
B. Document the findings and reassess in 30 minutes
C. Administer the next dose of morphine when due
D. Ask the patient to rate the pain on a 0–10 scale
Correct Answer:
A
Detailed Rationale:
The patient shows opioid-related respiratory depression:
decreased level of consciousness, bradypnea, and hypoxemia.
The nurse must act immediately to support airway/breathing
and oxygenation. This reflects recognition of deterioration and
rapid intervention to prevent respiratory failure.
Incorrect Option Analysis:
• B: Incorrect. Delaying action risks worsening hypoxemia
and respiratory arrest.
, o Misconception: Thinking documentation comes
before rescue.
o Safety Risk: Failure to intervene can lead to cardiac
arrest.
• C: Incorrect. Additional opioid would further suppress
respirations.
o Misconception: Treating pain without assessing
physiologic stability.
o Safety Risk: Severe oversedation and arrest.
• D: Incorrect. Pain scoring is not the priority in an unstable
patient.
o Misconception: Pain assessment always comes first.
o Safety Risk: Delays life-saving respiratory support.
Nursing Process Linkage:
Implementation
NCJMM Competencies:
Recognize Cues; Analyze Cues; Take Action
Difficulty Level:
Difficult
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
, Key Learning Objective:
Identify immediate nursing actions for medication-related
respiratory compromise.
2. MCQ
Clinical Scenario:
A nurse is caring for a patient with limited mobility and pain
after abdominal surgery. The care plan includes a goal that the
patient will ambulate 50 feet by discharge.
Question Stem:
Which nursing process step is demonstrated by this goal?
Answer Options:
A. Assessment
B. Nursing diagnosis
C. Planning
D. Evaluation
Correct Answer:
C
Detailed Rationale:
Writing a measurable outcome is part of planning. The nurse is
establishing a patient-centered, realistic goal that can later be
evaluated. Nursing process steps must link assessment data to
goals and interventions.
Incorrect Option Analysis:
