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 medical-surgical nurse begins a shift caring for four adult
patients. During report, the nurse learns that one patient has
developed increasing shortness of breath over the past hour.
Question Stem
Which nursing action best demonstrates the competency of
clinical judgment?
Answer Options
A. Reviewing all medication administration records before
seeing patients
B. Immediately assessing the patient with worsening shortness
of breath
C. Delegating vital signs to the nursing assistant
D. Completing documentation before patient rounds
Correct Answer
B. Immediately assessing the patient with worsening
shortness of breath
Detailed Rationale
Clinical judgment involves recognizing important cues,
prioritizing patient needs, and taking appropriate action.
Worsening dyspnea may indicate respiratory compromise
requiring prompt assessment and intervention. Prioritizing this
,patient demonstrates effective clinical reasoning and patient
safety awareness.
Incorrect Option Analysis
A
• Incorrect because record review is important but does not
address the most urgent concern.
• Misconception: Administrative tasks should always be
completed first.
• Safety Risk: Delayed recognition of deterioration.
C
• Incorrect because delegation should occur after priority
assessment.
• Misconception: Delegation replaces nursing assessment.
• Safety Risk: Critical changes may be missed.
D
• Incorrect because documentation is not the immediate
priority.
• Misconception: Documentation takes precedence over
assessment.
• Safety Risk: Delay in treatment.
Nursing Process Linkage
Assessment
, NCJMM Competencies
• Recognize Cues
• Prioritize Hypotheses
• Take Action
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Client Needs Category
Management of Care
Key Learning Objective
Prioritize nursing actions using clinical judgment principles.
Question 2 (MCQ)
Clinical Scenario
A nurse is developing a plan of care for a hospitalized patient
with heart failure.
Question Stem
Which component of the nursing process involves establishing
measurable patient outcomes?
Options