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 postoperative adult client on the surgical unit is 6 hours after
abdominal surgery. The client is restless, has a respiratory rate
of 28/min, is using accessory muscles, and has an SpO₂ of 88%
on room air.
Question stem:
What is the nurse’s priority first action?
Answer options:
A. Raise the head of the bed and apply supplemental oxygen
B. Encourage the client to use the incentive spirometer
C. Administer the prescribed opioid analgesic
D. Document the findings and reassess in 30 minutes
Correct answer: A
Detailed rationale:
The client shows signs of impaired oxygenation and possible
respiratory compromise. The nurse must act using the ABCs
and immediately support breathing by positioning the client
upright and applying oxygen.
Incorrect option analysis:
• B. Incorrect. Incentive spirometry is helpful, but it is not
the first action in acute hypoxemia.
Common misconception: Thinking preventive
interventions come before stabilization.
Patient safety risk: Delayed oxygen support may worsen
hypoxia.
, • C. Incorrect. Pain control may help breathing later, but
respiratory distress takes priority.
Common misconception: Assuming pain is the cause of all
tachypnea.
Patient safety risk: Giving opioids before addressing
hypoxemia may worsen respiratory depression.
• D. Incorrect. Documentation does not replace immediate
intervention.
Common misconception: Believing observation is enough
when the client is unstable.
Patient safety risk: Delayed treatment can lead to
respiratory failure.
Nursing process link: Implementation
NCJMM competency: Recognize Cues; Prioritize Hypotheses;
Take Action
Difficulty level: Moderate
Bloom’s level: Apply
NCLEX client needs: Physiological Adaptation
Learning objective: Prioritize immediate nursing actions for
acute respiratory compromise.
2. MCQ
Clinical scenario:
A client with heart failure says, “I know the dietitian says low
, sodium is important, but my family cooks traditional meals that
are usually salty.”
Question stem:
Which nurse response best reflects patient-centered care?
Answer options:
A. “You must follow the low-sodium diet exactly or your
condition will worsen.”
B. “Let’s identify your usual meals and work together on
realistic lower-sodium choices.”
C. “Ask your family to stop cooking those foods while you are
hospitalized.”
D. “I will document that you are noncompliant with the diet.”
Correct answer: B
Detailed rationale:
Patient-centered care respects the client’s values, culture, and
daily life while still promoting safe health outcomes. This
response invites collaboration and supports a realistic plan the
client is more likely to follow.
Incorrect option analysis:
• A. Incorrect. This is directive and noncollaborative.
Common misconception: Believing education alone
changes behavior.
Patient safety risk: The client may disengage and fail to
adhere after discharge.
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
1. MCQ
,Clinical scenario:
A postoperative adult client on the surgical unit is 6 hours after
abdominal surgery. The client is restless, has a respiratory rate
of 28/min, is using accessory muscles, and has an SpO₂ of 88%
on room air.
Question stem:
What is the nurse’s priority first action?
Answer options:
A. Raise the head of the bed and apply supplemental oxygen
B. Encourage the client to use the incentive spirometer
C. Administer the prescribed opioid analgesic
D. Document the findings and reassess in 30 minutes
Correct answer: A
Detailed rationale:
The client shows signs of impaired oxygenation and possible
respiratory compromise. The nurse must act using the ABCs
and immediately support breathing by positioning the client
upright and applying oxygen.
Incorrect option analysis:
• B. Incorrect. Incentive spirometry is helpful, but it is not
the first action in acute hypoxemia.
Common misconception: Thinking preventive
interventions come before stabilization.
Patient safety risk: Delayed oxygen support may worsen
hypoxia.
, • C. Incorrect. Pain control may help breathing later, but
respiratory distress takes priority.
Common misconception: Assuming pain is the cause of all
tachypnea.
Patient safety risk: Giving opioids before addressing
hypoxemia may worsen respiratory depression.
• D. Incorrect. Documentation does not replace immediate
intervention.
Common misconception: Believing observation is enough
when the client is unstable.
Patient safety risk: Delayed treatment can lead to
respiratory failure.
Nursing process link: Implementation
NCJMM competency: Recognize Cues; Prioritize Hypotheses;
Take Action
Difficulty level: Moderate
Bloom’s level: Apply
NCLEX client needs: Physiological Adaptation
Learning objective: Prioritize immediate nursing actions for
acute respiratory compromise.
2. MCQ
Clinical scenario:
A client with heart failure says, “I know the dietitian says low
, sodium is important, but my family cooks traditional meals that
are usually salty.”
Question stem:
Which nurse response best reflects patient-centered care?
Answer options:
A. “You must follow the low-sodium diet exactly or your
condition will worsen.”
B. “Let’s identify your usual meals and work together on
realistic lower-sodium choices.”
C. “Ask your family to stop cooking those foods while you are
hospitalized.”
D. “I will document that you are noncompliant with the diet.”
Correct answer: B
Detailed rationale:
Patient-centered care respects the client’s values, culture, and
daily life while still promoting safe health outcomes. This
response invites collaboration and supports a realistic plan the
client is more likely to follow.
Incorrect option analysis:
• A. Incorrect. This is directive and noncollaborative.
Common misconception: Believing education alone
changes behavior.
Patient safety risk: The client may disengage and fail to
adhere after discharge.
