Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• PublisherPublished by F.A.
Davis Copyright© 2024
• Print ISBN: 9781719647366
TEST BANK
,1. MCQ
Clinical Scenario
A medical-surgical nurse is receiving handoff report on four
adult patients.
Question Stem
Which patient should the nurse assess first?
Answer Options
A. A patient 1 day post-op who reports incisional pain of 6/10
B. A patient with a temperature of 37.8°C who is scheduled for
discharge
C. A patient who is newly confused, restless, and has an SpO₂ of
89% on room air
D. A patient requesting assistance to complete a meal tray
setup
Correct Answer
C
Detailed Rationale
New confusion, restlessness, and low oxygen saturation suggest
possible hypoxemia and acute deterioration. In clinical
judgment, the nurse must recognize cues that indicate a threat
to oxygenation and perfusion and respond first. Pain, mild
,temperature elevation, and meal setup are important but not
immediately life-threatening.
Incorrect Option Analysis
• A. Incorrect. Post-op pain is expected and should be
addressed, but it does not outrank possible oxygenation
failure.
Common misconception: All pain requires immediate
priority.
Safety risk: Delaying assessment of a deteriorating patient.
• B. Incorrect. A low-grade temperature is not as urgent as
altered mental status with hypoxemia.
Common misconception: Any abnormal vital sign is
automatically priority.
Safety risk: Missing respiratory compromise.
• D. Incorrect. This is a comfort/support need, not an urgent
threat.
Common misconception: Any patient request must be
answered first.
Safety risk: Failure to intervene in a rapidly worsening
condition.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues; Analyze Cues; Prioritize Hypotheses
, Difficulty Level
Moderate
Bloom’s Cognitive Level
Analyze
NCLEX Client Needs Category
Physiological Adaptation
Key Learning Objective
Prioritize patients using early deterioration cues and clinical
judgment.
2. MCQ
Clinical Scenario
A nurse is reviewing proposals for a new wound-care dressing
protocol on a medical-surgical unit.
Question Stem
Which source of evidence should the nurse value most when
deciding whether to adopt the new protocol?
Answer Options
A. A colleague’s personal experience with the dressing
B. A single expert opinion article
C. A systematic review or evidence-based guideline
D. The manufacturer’s promotional brochure