TEST BANK FOR MEDICAL-SURGICAL NURSING:
CONCEPTS FOR CLINICAL JUDGMENT AND
COLLABORATIVE CARE (11TH EDITION) AND
RATIONALES QUESTIONS & 100% VERIFIED
ANSWERS
CHAPTER 1
Professional Nursing Concepts, Clinical Judgment, and Patient Safety
1. The nurse is using the clinical judgment model. Which action represents
the “recognize cues” step?
A. Determining that a potassium of 2.8 mEq/L requires immediate action
B. Observing the client’s telemetry showing frequent PVCs
C. Calling the provider for a potassium replacement order
D. Evaluating whether potassium level improved after supplementation
Correct Answer: B
,Rationale: “Recognize cues” involves identifying relevant assessment findings
or data. PVCs are an observable cue. Interpreting, acting, and evaluating are later
steps.
11. A nurse receives a report about four clients. Which client requires
assessment first based on clinical judgment?
A. Client scheduled for discharge who needs reinforcement of medication
education
B. Client reporting pain rated 7/10 who is due for an analgesic in 30 minutes
C. Client with new-onset confusion and restlessness
D. Client requesting assistance to the bathroom
Correct Answer: C
Rationale: New confusion suggests acute neurological or oxygenation changes
and represents a change in condition, requiring immediate assessment. Pain
control and toileting are important but not emergent. Discharge teaching can
wait.
3. A nurse prepares to administer a high-risk medication. Which action
demonstrates adherence to patient-safety principles?
A. Verifying the drug using the electronic MAR only
B. Asking another nurse to check the medication barcode
C. Completing three checks and two identifiers before administration
D. Relying on pharmacy’s verification process
Correct Answer: C
Rationale: Safe medication administration requires three checks + two patient
identifiers. Safety is not delegated to pharmacists or other nurses.
,4. A nurse recognizes a potential safety hazard in the unit layout. What is the
nurse’s best action?
A. Fix the problem immediately
B. Document it in the nurses’ notes
C. Report the hazard through the facility’s safety reporting system
D. Ignore it unless an incident occurs
Correct Answer: C
Rationale: Reporting through the formal safety system supports Just
Culture, allowing hazards to be corrected proactively. Nurses should not
attempt repairs themselves.
5. A nurse caring for a client with sepsis notes decreased urine output,
cool skin, and hypotension. What is the nurse doing when identifying that
these cues indicate impaired perfusion?
A. Recognizing cues
B. Prioritizing hypotheses
C. Generating solutions
D. Evaluating outcomes
Correct Answer: B
Rationale: The nurse interprets and clusters cues to determine the most likely
problem—this is prioritizing hypotheses.
6. A client states, “I don’t understand what surgery I’m having.” What is the
nurse’s best response?
A. “Let me explain it to you.”
B. “Do you want to cancel the procedure?”
C. “I’ll notify the surgeon to clarify the procedure for you.”
D. “You signed the consent, so it should be clear.”
Correct Answer: C
, Rationale: The surgeon is responsible for informed consent, including
explanation of procedure, risks, and benefits. The nurse may reinforce but
not replace this teaching.
7. The nurse notes that an older adult client fell twice in 24 hours. Which
action reflects systems thinking?
A. Suggesting the client needs a sitter
B. Reviewing unit staffing and environmental risks
C. Asking the client to request help more often
D. Documenting both falls accurately
Correct Answer: B
Rationale: Systems thinking assesses unit-wide factors, equipment, policies,
and staffing—not only client behaviors.
8. During handoff, which statement shows SBAR best practice?
A. “He doesn’t look good today.”
B. “He might be getting worse; I’m not sure.”
C. “BP dropped to 88/50 in the past hour; requesting evaluation for possible
fluids.”
D. “I think he needs more attention.”
Correct Answer: C
Rationale: SBAR requires objective, specific data and a clear
recommendation.
CONCEPTS FOR CLINICAL JUDGMENT AND
COLLABORATIVE CARE (11TH EDITION) AND
RATIONALES QUESTIONS & 100% VERIFIED
ANSWERS
CHAPTER 1
Professional Nursing Concepts, Clinical Judgment, and Patient Safety
1. The nurse is using the clinical judgment model. Which action represents
the “recognize cues” step?
A. Determining that a potassium of 2.8 mEq/L requires immediate action
B. Observing the client’s telemetry showing frequent PVCs
C. Calling the provider for a potassium replacement order
D. Evaluating whether potassium level improved after supplementation
Correct Answer: B
,Rationale: “Recognize cues” involves identifying relevant assessment findings
or data. PVCs are an observable cue. Interpreting, acting, and evaluating are later
steps.
11. A nurse receives a report about four clients. Which client requires
assessment first based on clinical judgment?
A. Client scheduled for discharge who needs reinforcement of medication
education
B. Client reporting pain rated 7/10 who is due for an analgesic in 30 minutes
C. Client with new-onset confusion and restlessness
D. Client requesting assistance to the bathroom
Correct Answer: C
Rationale: New confusion suggests acute neurological or oxygenation changes
and represents a change in condition, requiring immediate assessment. Pain
control and toileting are important but not emergent. Discharge teaching can
wait.
3. A nurse prepares to administer a high-risk medication. Which action
demonstrates adherence to patient-safety principles?
A. Verifying the drug using the electronic MAR only
B. Asking another nurse to check the medication barcode
C. Completing three checks and two identifiers before administration
D. Relying on pharmacy’s verification process
Correct Answer: C
Rationale: Safe medication administration requires three checks + two patient
identifiers. Safety is not delegated to pharmacists or other nurses.
,4. A nurse recognizes a potential safety hazard in the unit layout. What is the
nurse’s best action?
A. Fix the problem immediately
B. Document it in the nurses’ notes
C. Report the hazard through the facility’s safety reporting system
D. Ignore it unless an incident occurs
Correct Answer: C
Rationale: Reporting through the formal safety system supports Just
Culture, allowing hazards to be corrected proactively. Nurses should not
attempt repairs themselves.
5. A nurse caring for a client with sepsis notes decreased urine output,
cool skin, and hypotension. What is the nurse doing when identifying that
these cues indicate impaired perfusion?
A. Recognizing cues
B. Prioritizing hypotheses
C. Generating solutions
D. Evaluating outcomes
Correct Answer: B
Rationale: The nurse interprets and clusters cues to determine the most likely
problem—this is prioritizing hypotheses.
6. A client states, “I don’t understand what surgery I’m having.” What is the
nurse’s best response?
A. “Let me explain it to you.”
B. “Do you want to cancel the procedure?”
C. “I’ll notify the surgeon to clarify the procedure for you.”
D. “You signed the consent, so it should be clear.”
Correct Answer: C
, Rationale: The surgeon is responsible for informed consent, including
explanation of procedure, risks, and benefits. The nurse may reinforce but
not replace this teaching.
7. The nurse notes that an older adult client fell twice in 24 hours. Which
action reflects systems thinking?
A. Suggesting the client needs a sitter
B. Reviewing unit staffing and environmental risks
C. Asking the client to request help more often
D. Documenting both falls accurately
Correct Answer: B
Rationale: Systems thinking assesses unit-wide factors, equipment, policies,
and staffing—not only client behaviors.
8. During handoff, which statement shows SBAR best practice?
A. “He doesn’t look good today.”
B. “He might be getting worse; I’m not sure.”
C. “BP dropped to 88/50 in the past hour; requesting evaluation for possible
fluids.”
D. “I think he needs more attention.”
Correct Answer: C
Rationale: SBAR requires objective, specific data and a clear
recommendation.
