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 four patients on a medical-surgical unit.
Which patient should the nurse assess first?
• A patient with chronic heart failure reporting mild ankle
swelling.
• A patient 2 days post-op requesting pain medication.
• A patient with pneumonia whose oxygen saturation has
dropped from 95% to 88% on room air.
• A patient with diabetes asking questions about diet.
Question
Which patient should the nurse assess first?
Options
A.
Chronic heart failure with ankle swelling
B.
Postoperative patient requesting pain medication
C.
Pneumonia patient with SpO₂ 88%
D.
Patient with diabetes requesting education
Answer and Rationale
,Correct Answer
C. Pneumonia patient with SpO₂ 88%
Rationale: A drop in oxygen saturation to 88% indicates
impaired oxygenation and possible clinical deterioration. Using
the ABC framework (Airway, Breathing, Circulation), breathing
problems take priority. Early recognition of hypoxemia is a key
clinical judgment competency.
Incorrect Option Analysis
A. Heart failure with ankle swelling
Incorrect
Why incorrect: Mild edema is important but not immediately
life-threatening.
Misconception: Assuming all heart failure findings are urgent.
Safety risk: Delaying assessment of hypoxemia.
B. Requesting pain medication
Incorrect
Why incorrect: Pain requires timely treatment but is lower
priority than impaired oxygenation.
Misconception: Prioritizing patient requests over physiological
instability.
Safety risk: Missing respiratory compromise.
D. Diabetes education
, Incorrect
Why incorrect: Education can be provided after urgent needs
are addressed.
Safety risk: Delayed intervention for a deteriorating patient.
Clinical Judgment & Exam Blueprint
Nursing Process: Assessment
NCJMM: Recognize Cues
NCJMM: Prioritize Hypotheses
Difficulty: Moderate
Bloom: Analyze
NCLEX: Physiological Adaptation
Key Learning Objective: Prioritize patient care using ABCs and
recognition of clinical deterioration.
Question 2 (SATA)
Clinical Scenario
A nurse is implementing evidence-based practice on a medical-
surgical unit.
Question
Which actions reflect evidence-based nursing care? Select all
that apply.
Answer and Rationale