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 72-year-old patient is admitted after abdominal surgery.
While turning in bed, the patient says, “I suddenly feel short of
breath,” and becomes restless. The pulse oximeter reads 86%
on room air, respiratory rate is 28/min, and the patient is using
accessory muscles.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Raise the head of the bed and apply oxygen as prescribed
B. Document the finding and reassess in 15 minutes
C. Encourage the patient to use the incentive spirometer
D. Ask the nursing assistant to obtain a new set of vital signs
Correct Answer:
A. Raise the head of the bed and apply oxygen as prescribed
Detailed Rationale:
The patient shows acute respiratory distress, which is a priority
ABC problem. Raising the head of the bed improves lung
expansion, and oxygen supports immediate oxygenation while
further assessment and escalation occur. The nurse must act
quickly because hypoxemia can deteriorate rapidly.
Incorrect Option Analysis:
, • B is incorrect because waiting is unsafe when oxygen
saturation is already low.
o Common misconception: believing reassessment can
replace immediate intervention.
o Safety risk: delayed treatment may worsen hypoxia
and respiratory failure.
• C is incorrect because incentive spirometry is not the first
action during acute distress.
o Common misconception: confusing preventive
teaching with emergency intervention.
o Safety risk: the patient may decompensate while the
nurse delays oxygen support.
• D is incorrect because an assistant cannot replace the
nurse’s immediate assessment and intervention.
o Common misconception: delegating urgent care to
the team too early.
o Safety risk: delay in recognizing respiratory
compromise.
Nursing Process Linkage:
Implementation
NCJMM Competencies:
Recognize Cues; Take Action
, Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Prioritize immediate nursing action for acute respiratory
deterioration using airway/breathing cues.
2) SATA
Clinical Scenario:
A post-operative patient is 4 hours after surgery. The nurse is
reviewing the chart and assessing for early signs of
deterioration.
Question Stem:
Which findings are objective cues that may indicate the patient
needs further follow-up? Select all that apply.
Answer Options:
A. Heart rate 118/min
B. Blood pressure 88/54 mm Hg
C. Urine output 15 mL/hr
D. The patient says, “I feel dizzy when I sit up.”
E. Skin is warm, dry, and pink
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Clinical Scenario:
A 72-year-old patient is admitted after abdominal surgery.
While turning in bed, the patient says, “I suddenly feel short of
breath,” and becomes restless. The pulse oximeter reads 86%
on room air, respiratory rate is 28/min, and the patient is using
accessory muscles.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Raise the head of the bed and apply oxygen as prescribed
B. Document the finding and reassess in 15 minutes
C. Encourage the patient to use the incentive spirometer
D. Ask the nursing assistant to obtain a new set of vital signs
Correct Answer:
A. Raise the head of the bed and apply oxygen as prescribed
Detailed Rationale:
The patient shows acute respiratory distress, which is a priority
ABC problem. Raising the head of the bed improves lung
expansion, and oxygen supports immediate oxygenation while
further assessment and escalation occur. The nurse must act
quickly because hypoxemia can deteriorate rapidly.
Incorrect Option Analysis:
, • B is incorrect because waiting is unsafe when oxygen
saturation is already low.
o Common misconception: believing reassessment can
replace immediate intervention.
o Safety risk: delayed treatment may worsen hypoxia
and respiratory failure.
• C is incorrect because incentive spirometry is not the first
action during acute distress.
o Common misconception: confusing preventive
teaching with emergency intervention.
o Safety risk: the patient may decompensate while the
nurse delays oxygen support.
• D is incorrect because an assistant cannot replace the
nurse’s immediate assessment and intervention.
o Common misconception: delegating urgent care to
the team too early.
o Safety risk: delay in recognizing respiratory
compromise.
Nursing Process Linkage:
Implementation
NCJMM Competencies:
Recognize Cues; Take Action
, Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Prioritize immediate nursing action for acute respiratory
deterioration using airway/breathing cues.
2) SATA
Clinical Scenario:
A post-operative patient is 4 hours after surgery. The nurse is
reviewing the chart and assessing for early signs of
deterioration.
Question Stem:
Which findings are objective cues that may indicate the patient
needs further follow-up? Select all that apply.
Answer Options:
A. Heart rate 118/min
B. Blood pressure 88/54 mm Hg
C. Urine output 15 mL/hr
D. The patient says, “I feel dizzy when I sit up.”
E. Skin is warm, dry, and pink
