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 is caring for a 68-year-old patient admitted with
community-acquired pneumonia. During morning assessment,
the nurse notes increased respiratory rate, confusion, and
oxygen saturation decreased from 95% to 88% on room air.
Question Stem
Which nursing action best demonstrates clinical judgment?
Answer Options
A. Document the findings and reassess in 4 hours
B. Administer the scheduled antibiotic and continue monitoring
C. Notify the provider immediately and initiate oxygen therapy
per protocol
D. Ask the nursing assistant to repeat the vital signs later
Correct Answer
C. Notify the provider immediately and initiate oxygen
therapy per protocol
Detailed Rationale
The patient demonstrates signs of deterioration including
hypoxemia, tachypnea, and altered mental status. Clinical
judgment requires recognition of cues, analysis of their
significance, and prompt intervention. Early oxygen
administration and provider notification may prevent
respiratory failure.
Incorrect Option Analysis
,A. Document and reassess
• Incorrect because deterioration requires immediate
intervention.
• Misconception: Documentation alone addresses the
problem.
• Safety Risk: Delayed treatment may worsen hypoxia.
B. Give antibiotic only
• Incorrect because airway and oxygenation are priority
needs.
• Misconception: Treating infection immediately resolves
instability.
• Safety Risk: Respiratory compromise may progress.
D. Delegate reassessment
• Incorrect because assessment and interpretation are RN
responsibilities.
• Misconception: Vital sign repetition replaces clinical
analysis.
• Safety Risk: Delayed recognition of deterioration.
Nursing Process Linkage
Assessment
NCJMM Competencies
• Recognize Cues
, • Analyze Cues
• Take Action
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Client Needs
Physiological Adaptation
Key Learning Objective
Apply clinical judgment when identifying patient deterioration.
Question 2 (MCQ)
Clinical Scenario
A newly licensed nurse asks why evidence-based practice is
important.
Question Stem
Which statement best describes evidence-based nursing care?
Answer Options
A. Care based solely on provider preference
B. Care guided by tradition and routine