Davis Advantage for Medical-
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Clinical Scenario:
A post-operative adult returns to the unit after abdominal
surgery. Fifteen minutes later, the nurse notes that the patient
is increasingly drowsy, respirations are 10/min, and oxygen
saturation has dropped from 97% to 89% on 2 L/min nasal
cannula.
Question Stem:
What should the nurse do first?
Answer Options:
A. Document the change in the chart
B. Increase the IV rate
C. Assess airway and breathing immediately
D. Notify the surgeon after the next vital-sign check
Correct Answer:
C. Assess airway and breathing immediately
Detailed Rationale:
The priority is airway and breathing because the patient shows
signs of respiratory compromise. In clinical judgment terms, the
nurse is recognizing cues and taking immediate action to
prevent deterioration. Assessment comes before notification
when the patient may be unstable.
Incorrect Option Analysis:
, • A. Document the change in the chart — Incorrect because
documentation must never delay urgent assessment.
Common misconception: Charting is seen as the “next
step” in all situations.
Safety risk: Delayed intervention can worsen hypoxemia.
• B. Increase the IV rate — Incorrect because this does not
address the immediate respiratory problem.
Common misconception: Assuming low oxygen saturation
is due to volume status.
Safety risk: Fails to treat potential airway or ventilatory
compromise.
• D. Notify the surgeon after the next vital-sign check —
Incorrect because waiting is unsafe.
Common misconception: Believing provider notification is
the first step in all abnormal findings.
Safety risk: Delays escalation during a potentially life-
threatening event.
Nursing Process Linkage:
Assessment
NCJMM Competencies:
Recognize Cues; Take Action
Difficulty Level:
Difficult
Bloom’s Cognitive Level:
Analyze
, NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Prioritize immediate assessment and intervention for signs of
acute respiratory deterioration.
2) MCQ
Clinical Scenario:
A nursing instructor asks a student to describe the evaluation
phase of the nursing process.
Question Stem:
Which response is best?
Answer Options:
A. “It is when the nurse collects baseline data.”
B. “It is when the nurse compares outcomes with goals.”
C. “It is when the nurse identifies priorities.”
D. “It is when the nurse selects interventions.”
Correct Answer:
B. “It is when the nurse compares outcomes with goals.”
Detailed Rationale:
Evaluation involves determining whether the patient’s
responses meet the expected outcomes. This is the phase
where the nurse decides whether the plan was effective and
whether revision is needed.
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Clinical Scenario:
A post-operative adult returns to the unit after abdominal
surgery. Fifteen minutes later, the nurse notes that the patient
is increasingly drowsy, respirations are 10/min, and oxygen
saturation has dropped from 97% to 89% on 2 L/min nasal
cannula.
Question Stem:
What should the nurse do first?
Answer Options:
A. Document the change in the chart
B. Increase the IV rate
C. Assess airway and breathing immediately
D. Notify the surgeon after the next vital-sign check
Correct Answer:
C. Assess airway and breathing immediately
Detailed Rationale:
The priority is airway and breathing because the patient shows
signs of respiratory compromise. In clinical judgment terms, the
nurse is recognizing cues and taking immediate action to
prevent deterioration. Assessment comes before notification
when the patient may be unstable.
Incorrect Option Analysis:
, • A. Document the change in the chart — Incorrect because
documentation must never delay urgent assessment.
Common misconception: Charting is seen as the “next
step” in all situations.
Safety risk: Delayed intervention can worsen hypoxemia.
• B. Increase the IV rate — Incorrect because this does not
address the immediate respiratory problem.
Common misconception: Assuming low oxygen saturation
is due to volume status.
Safety risk: Fails to treat potential airway or ventilatory
compromise.
• D. Notify the surgeon after the next vital-sign check —
Incorrect because waiting is unsafe.
Common misconception: Believing provider notification is
the first step in all abnormal findings.
Safety risk: Delays escalation during a potentially life-
threatening event.
Nursing Process Linkage:
Assessment
NCJMM Competencies:
Recognize Cues; Take Action
Difficulty Level:
Difficult
Bloom’s Cognitive Level:
Analyze
, NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Prioritize immediate assessment and intervention for signs of
acute respiratory deterioration.
2) MCQ
Clinical Scenario:
A nursing instructor asks a student to describe the evaluation
phase of the nursing process.
Question Stem:
Which response is best?
Answer Options:
A. “It is when the nurse collects baseline data.”
B. “It is when the nurse compares outcomes with goals.”
C. “It is when the nurse identifies priorities.”
D. “It is when the nurse selects interventions.”
Correct Answer:
B. “It is when the nurse compares outcomes with goals.”
Detailed Rationale:
Evaluation involves determining whether the patient’s
responses meet the expected outcomes. This is the phase
where the nurse decides whether the plan was effective and
whether revision is needed.
