Davis Advantage for Medical-
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
Question 1 — MCQ
,Clinical Scenario
A nurse on a medical-surgical unit is caring for a 72-year-old
patient admitted with community-acquired pneumonia. During
morning assessment, the nurse notes increasing confusion,
respiratory rate of 30 breaths/min, oxygen saturation of 88%
on 2 L nasal cannula, and new restlessness.
Question Stem
Which nursing action best demonstrates clinical judgment?
Answer Options
A. Document the assessment findings and reassess in 4 hours
B. Increase oxygen flow rate independently to 10 L/min via
nonrebreather mask
C. Notify the rapid response team and communicate
assessment findings promptly
D. Ask the nursing assistant to repeat the vital signs in 30
minutes
Correct Answer
C. Notify the rapid response team and communicate
assessment findings promptly
Detailed Rationale
The patient is demonstrating signs of clinical deterioration
including hypoxemia, tachypnea, acute confusion, and
restlessness. These findings suggest worsening respiratory
,compromise and possible sepsis. Clinical judgment involves
recognizing significant cues, prioritizing hypotheses, and taking
timely action to prevent further deterioration.
Activating the rapid response team promotes early
intervention, interdisciplinary collaboration, and patient safety.
Incorrect Option Analysis
A. Document the assessment findings and reassess in 4 hours
• Why Incorrect: Delays intervention for an unstable
patient.
• Common Misconception: Believing documentation alone
fulfills nursing responsibility.
• Patient Safety Risk: Respiratory failure or septic shock
may develop.
B. Increase oxygen flow rate independently to 10 L/min via
nonrebreather mask
• Why Incorrect: Oxygen escalation may exceed nursing
protocols.
• Common Misconception: Treating oxygen saturation
without evaluating the underlying cause.
• Patient Safety Risk: Delays comprehensive emergency
management.
, D. Ask the nursing assistant to repeat the vital signs in 30
minutes
• Why Incorrect: Delegates reassessment of an unstable
patient inappropriately.
• Common Misconception: Assuming abnormal findings are
inaccurate.
• Patient Safety Risk: Delayed recognition of clinical decline.
Nursing Process Linkage
Assessment
NCJMM Competencies
• Recognize Cues
• Analyze Cues
• Take Action
Difficulty Level
Moderate
Bloom’s Cognitive Level
Analyze
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
Question 1 — MCQ
,Clinical Scenario
A nurse on a medical-surgical unit is caring for a 72-year-old
patient admitted with community-acquired pneumonia. During
morning assessment, the nurse notes increasing confusion,
respiratory rate of 30 breaths/min, oxygen saturation of 88%
on 2 L nasal cannula, and new restlessness.
Question Stem
Which nursing action best demonstrates clinical judgment?
Answer Options
A. Document the assessment findings and reassess in 4 hours
B. Increase oxygen flow rate independently to 10 L/min via
nonrebreather mask
C. Notify the rapid response team and communicate
assessment findings promptly
D. Ask the nursing assistant to repeat the vital signs in 30
minutes
Correct Answer
C. Notify the rapid response team and communicate
assessment findings promptly
Detailed Rationale
The patient is demonstrating signs of clinical deterioration
including hypoxemia, tachypnea, acute confusion, and
restlessness. These findings suggest worsening respiratory
,compromise and possible sepsis. Clinical judgment involves
recognizing significant cues, prioritizing hypotheses, and taking
timely action to prevent further deterioration.
Activating the rapid response team promotes early
intervention, interdisciplinary collaboration, and patient safety.
Incorrect Option Analysis
A. Document the assessment findings and reassess in 4 hours
• Why Incorrect: Delays intervention for an unstable
patient.
• Common Misconception: Believing documentation alone
fulfills nursing responsibility.
• Patient Safety Risk: Respiratory failure or septic shock
may develop.
B. Increase oxygen flow rate independently to 10 L/min via
nonrebreather mask
• Why Incorrect: Oxygen escalation may exceed nursing
protocols.
• Common Misconception: Treating oxygen saturation
without evaluating the underlying cause.
• Patient Safety Risk: Delays comprehensive emergency
management.
, D. Ask the nursing assistant to repeat the vital signs in 30
minutes
• Why Incorrect: Delegates reassessment of an unstable
patient inappropriately.
• Common Misconception: Assuming abnormal findings are
inaccurate.
• Patient Safety Risk: Delayed recognition of clinical decline.
Nursing Process Linkage
Assessment
NCJMM Competencies
• Recognize Cues
• Analyze Cues
• Take Action
Difficulty Level
Moderate
Bloom’s Cognitive Level
Analyze
