Test Bank for Medical-Surgical Nursing Focus on
Clinical Judgment 3rd Edition by Honan | All
Chapters 1-56 Complete New Edition | ISBN:
9781975190941
UNIT 1: FOUNDATIONS OF MEDICAL-SURGICAL NURSING
Chapters 1-4
Chapter 1: Clinical Judgment and the Professional Nurse
Question 1
A nurse is caring for a client with acute pain. The nurse develops a list of interventions
including medication administration, repositioning, and non-pharmacological methods.
This is an example of which CJMM step?
A) Analyze cues
B) Generate solutions
C) Prioritize hypotheses
D) Take action
,Correct Answer: B) Generate solutions
Rationale: Generating solutions involves developing a list of potential interventions
to address the prioritized hypotheses. The nurse identifies multiple interventions for
pain management. Analyze cues (A) is interpreting data. Prioritize hypotheses (C)
comes before generating solutions. Take action (D) is implementation .
Question 2
A nurse administers an analgesic to a client with pain and then asks the client to rate the
pain on a 0-10 scale. This is an example of which CJMM step?
A) Generate solutions
B) Take action
C) Evaluate outcomes
D) Recognize cues
Correct Answer: C) Evaluate outcomes
Rationale: Evaluating outcomes involves reassessing the client after implementing
interventions to determine if the interventions were effective. The nurse administers
the analgesic and then reassesses the pain level. Take action (B) is the
administration itself .
Question 3
A nurse is preparing to discharge a client. Which action is most important to prevent
readmission?
A) Ensure the client has a ride home
B) Provide clear, understandable discharge instructions and assess the client's
understanding
C) Review the client's medication list
D) Schedule a follow-up appointment
,Correct Answer: B) Provide clear, understandable discharge instructions and assess
the client's understanding
Rationale: Providing clear discharge instructions and assessing the client's
understanding using teach-back methodology is the most important action to
prevent readmission. A ride home (A), medication review (C), and follow-up
appointments (D) are important but do not ensure the client understands how to
manage their care at home .
Question 4
A nurse is caring for a client who is postoperative following abdominal surgery. The
client reports pain of 7 on a 0-10 scale. Which action demonstrates clinical judgment?
A) Administering the prescribed analgesic immediately
B) Assessing the client's pain characteristics and vital signs before administering
medication
C) Waiting until the next scheduled pain medication time
D) Calling the provider for a different pain medication order
Correct Answer: B) Assessing the client's pain characteristics and vital signs before
administering medication
Rationale: Clinical judgment involves assessing the client's condition, gathering
relevant data, and evaluating the situation before implementing interventions.
Assessing pain characteristics and vital signs demonstrates clinical reasoning.
Administering the medication immediately without assessment (A) is a task-
oriented action that bypasses the clinical judgment process. Waiting (C) would
delay necessary pain relief. Calling the provider (D) is premature without a
comprehensive assessment .
Question 5
A new graduate nurse is developing clinical judgment skills. Which action indicates
progression toward competent clinical judgment?
, A) Following policies and procedures without questioning
B) Recognizing patterns in client data and anticipating potential complications
C) Relying solely on the primary provider's orders
D) Avoiding making independent clinical decisions
Correct Answer: B) Recognizing patterns in client data and anticipating potential
complications
Rationale: Competent clinical judgment involves recognizing patterns, anticipating
complications, and making informed clinical decisions based on assessment data.
Following policies without questioning (A) does not demonstrate critical thinking.
Relying solely on provider orders (C) and avoiding independent decisions (D)
indicate a lack of clinical judgment development .
Question 6
A nurse is caring for a client who develops respiratory distress. According to the Clinical
Judgment Measurement Model (CJMM), which step should the nurse perform FIRST?
A) Generate solutions
B) Take action
C) Recognize cues
D) Evaluate outcomes
Correct Answer: C) Recognize cues
Rationale: The correct order of the CJMM is: Recognize cues → Analyze cues →
Prioritize hypotheses → Generate solutions → Take action → Evaluate outcomes.
Recognizing cues involves identifying relevant clinical data (assessment findings,
vital signs, client reports) .
Question 7
A nurse has identified that a client's surgical incision is red, warm, and draining purulent
Clinical Judgment 3rd Edition by Honan | All
Chapters 1-56 Complete New Edition | ISBN:
9781975190941
UNIT 1: FOUNDATIONS OF MEDICAL-SURGICAL NURSING
Chapters 1-4
Chapter 1: Clinical Judgment and the Professional Nurse
Question 1
A nurse is caring for a client with acute pain. The nurse develops a list of interventions
including medication administration, repositioning, and non-pharmacological methods.
This is an example of which CJMM step?
A) Analyze cues
B) Generate solutions
C) Prioritize hypotheses
D) Take action
,Correct Answer: B) Generate solutions
Rationale: Generating solutions involves developing a list of potential interventions
to address the prioritized hypotheses. The nurse identifies multiple interventions for
pain management. Analyze cues (A) is interpreting data. Prioritize hypotheses (C)
comes before generating solutions. Take action (D) is implementation .
Question 2
A nurse administers an analgesic to a client with pain and then asks the client to rate the
pain on a 0-10 scale. This is an example of which CJMM step?
A) Generate solutions
B) Take action
C) Evaluate outcomes
D) Recognize cues
Correct Answer: C) Evaluate outcomes
Rationale: Evaluating outcomes involves reassessing the client after implementing
interventions to determine if the interventions were effective. The nurse administers
the analgesic and then reassesses the pain level. Take action (B) is the
administration itself .
Question 3
A nurse is preparing to discharge a client. Which action is most important to prevent
readmission?
A) Ensure the client has a ride home
B) Provide clear, understandable discharge instructions and assess the client's
understanding
C) Review the client's medication list
D) Schedule a follow-up appointment
,Correct Answer: B) Provide clear, understandable discharge instructions and assess
the client's understanding
Rationale: Providing clear discharge instructions and assessing the client's
understanding using teach-back methodology is the most important action to
prevent readmission. A ride home (A), medication review (C), and follow-up
appointments (D) are important but do not ensure the client understands how to
manage their care at home .
Question 4
A nurse is caring for a client who is postoperative following abdominal surgery. The
client reports pain of 7 on a 0-10 scale. Which action demonstrates clinical judgment?
A) Administering the prescribed analgesic immediately
B) Assessing the client's pain characteristics and vital signs before administering
medication
C) Waiting until the next scheduled pain medication time
D) Calling the provider for a different pain medication order
Correct Answer: B) Assessing the client's pain characteristics and vital signs before
administering medication
Rationale: Clinical judgment involves assessing the client's condition, gathering
relevant data, and evaluating the situation before implementing interventions.
Assessing pain characteristics and vital signs demonstrates clinical reasoning.
Administering the medication immediately without assessment (A) is a task-
oriented action that bypasses the clinical judgment process. Waiting (C) would
delay necessary pain relief. Calling the provider (D) is premature without a
comprehensive assessment .
Question 5
A new graduate nurse is developing clinical judgment skills. Which action indicates
progression toward competent clinical judgment?
, A) Following policies and procedures without questioning
B) Recognizing patterns in client data and anticipating potential complications
C) Relying solely on the primary provider's orders
D) Avoiding making independent clinical decisions
Correct Answer: B) Recognizing patterns in client data and anticipating potential
complications
Rationale: Competent clinical judgment involves recognizing patterns, anticipating
complications, and making informed clinical decisions based on assessment data.
Following policies without questioning (A) does not demonstrate critical thinking.
Relying solely on provider orders (C) and avoiding independent decisions (D)
indicate a lack of clinical judgment development .
Question 6
A nurse is caring for a client who develops respiratory distress. According to the Clinical
Judgment Measurement Model (CJMM), which step should the nurse perform FIRST?
A) Generate solutions
B) Take action
C) Recognize cues
D) Evaluate outcomes
Correct Answer: C) Recognize cues
Rationale: The correct order of the CJMM is: Recognize cues → Analyze cues →
Prioritize hypotheses → Generate solutions → Take action → Evaluate outcomes.
Recognizing cues involves identifying relevant clinical data (assessment findings,
vital signs, client reports) .
Question 7
A nurse has identified that a client's surgical incision is red, warm, and draining purulent
