Davis Advantage for Medical-
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,Clinical Scenario:
A postoperative patient on the med-surg unit says, “I suddenly
feel short of breath and very anxious,” after walking to the
bathroom. 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 first action?
Answer Options:
A. Administer the prescribed PRN opioid for discomfort
B. Place the patient in high Fowler’s position and reassess
breathing and oxygen saturation
C. Document the finding and reassess at the end of the shift
D. Encourage incentive spirometry and ambulation
Correct Answer:
B
Detailed Rationale:
This patient has new respiratory compromise and requires
immediate assessment and supportive intervention. High
Fowler’s improves lung expansion and reassessment helps
determine severity and guide escalation. This reflects recognize
cues → take action in clinical judgment.
Incorrect Option Analysis:
• A. Incorrect. Opioids can worsen respiratory depression.
Misconception: Treating discomfort before stabilizing
, breathing.
Safety risk: Delayed response to hypoxemia.
• C. Incorrect. This delays urgent intervention.
Misconception: Documentation can come before
stabilization.
Safety risk: Missed deterioration.
• D. Incorrect. These measures may be appropriate later,
but not as the first response.
Misconception: Routine pulmonary hygiene is enough for
acute distress.
Safety risk: Worsening hypoxia.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues; Take Action
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective:
Prioritize immediate nursing actions for acute respiratory
change.
2) MCQ
, Clinical Scenario:
A new nurse asks where to find the best evidence for a dressing
change procedure on the unit.
Question Stem:
Which source best supports evidence-based nursing care?
Answer Options:
A. A coworker’s memory of how the procedure was done years
ago
B. A textbook from nursing school published 8 years ago
C. The current unit policy based on updated clinical guidelines
D. A blog post written by a healthcare influencer
Correct Answer:
C
Detailed Rationale:
Evidence-based practice uses the best current evidence, clinical
expertise, and patient preferences. Current unit policy that
reflects updated guidelines is the most appropriate source in
this list.
Incorrect Option Analysis:
• A. Incorrect. Informal memory is not reliable evidence.
Misconception: Experience alone equals best practice.
Safety risk: Outdated or unsafe care.
• B. Incorrect. Older textbooks may be helpful for basics,
but may not reflect current standards.
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,Clinical Scenario:
A postoperative patient on the med-surg unit says, “I suddenly
feel short of breath and very anxious,” after walking to the
bathroom. 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 first action?
Answer Options:
A. Administer the prescribed PRN opioid for discomfort
B. Place the patient in high Fowler’s position and reassess
breathing and oxygen saturation
C. Document the finding and reassess at the end of the shift
D. Encourage incentive spirometry and ambulation
Correct Answer:
B
Detailed Rationale:
This patient has new respiratory compromise and requires
immediate assessment and supportive intervention. High
Fowler’s improves lung expansion and reassessment helps
determine severity and guide escalation. This reflects recognize
cues → take action in clinical judgment.
Incorrect Option Analysis:
• A. Incorrect. Opioids can worsen respiratory depression.
Misconception: Treating discomfort before stabilizing
, breathing.
Safety risk: Delayed response to hypoxemia.
• C. Incorrect. This delays urgent intervention.
Misconception: Documentation can come before
stabilization.
Safety risk: Missed deterioration.
• D. Incorrect. These measures may be appropriate later,
but not as the first response.
Misconception: Routine pulmonary hygiene is enough for
acute distress.
Safety risk: Worsening hypoxia.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues; Take Action
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective:
Prioritize immediate nursing actions for acute respiratory
change.
2) MCQ
, Clinical Scenario:
A new nurse asks where to find the best evidence for a dressing
change procedure on the unit.
Question Stem:
Which source best supports evidence-based nursing care?
Answer Options:
A. A coworker’s memory of how the procedure was done years
ago
B. A textbook from nursing school published 8 years ago
C. The current unit policy based on updated clinical guidelines
D. A blog post written by a healthcare influencer
Correct Answer:
C
Detailed Rationale:
Evidence-based practice uses the best current evidence, clinical
expertise, and patient preferences. Current unit policy that
reflects updated guidelines is the most appropriate source in
this list.
Incorrect Option Analysis:
• A. Incorrect. Informal memory is not reliable evidence.
Misconception: Experience alone equals best practice.
Safety risk: Outdated or unsafe care.
• B. Incorrect. Older textbooks may be helpful for basics,
but may not reflect current standards.
