Davis Advantage for Medical-
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• PublisherPublished by F.A.
Davis Copyright© 2024
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Clinical Scenario:
A postoperative patient becomes pale and restless. The nurse
notes a heart rate of 118/min, blood pressure of 88/54 mm Hg,
and urine output of 15 mL/hr over the last 2 hours.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Document the findings in the chart
B. Reassess the patient in 30 minutes
C. Perform a focused assessment and compare with baseline
data
D. Administer the prescribed PRN pain medication
Correct Answer:
C
Detailed Rationale:
The nurse must first assess because the cues suggest possible
clinical deterioration. A focused assessment helps determine
the cause of instability and guides timely intervention. This
reflects the first step of clinical judgment: recognize and
analyze cues.
Incorrect Option Analysis:
, • A. Document the findings in the chart — Incorrect
because documentation should follow assessment and
appropriate action.
o Misconception: Charting alone is enough.
o Safety risk: Delays intervention for possible shock or
bleeding.
• B. Reassess the patient in 30 minutes — Incorrect
because the findings are abnormal and urgent.
o Misconception: Waiting is acceptable when the
patient is “still awake.”
o Safety risk: Missed early deterioration.
• D. Administer the prescribed PRN pain medication —
Incorrect because pain medication does not address
hemodynamic instability.
o Misconception: Treating discomfort is the priority
over abnormal vital signs.
o Safety risk: May worsen hypotension or mask
worsening status.
Nursing Process Linkage:
Assessment
NCJMM Competency:
Recognize Cues, Analyze Cues
, Difficulty Level:
Difficult
Bloom’s Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Prioritize assessment when findings suggest acute patient
deterioration.
2) MCQ
Clinical Scenario:
An older adult admitted to the medical-surgical unit says, “I
want my daughter present when you explain anything to me,
and I hear better if I wear my hearing aid.”
Question Stem:
Which action best reflects patient-centered care?
Answer Options:
A. Provide teaching quickly while the patient is alone
B. Give printed materials and leave the room
C. Include the daughter and ensure the hearing aid is in place
before teaching
D. Tell the patient to ask questions after discharge
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• PublisherPublished by F.A.
Davis Copyright© 2024
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Clinical Scenario:
A postoperative patient becomes pale and restless. The nurse
notes a heart rate of 118/min, blood pressure of 88/54 mm Hg,
and urine output of 15 mL/hr over the last 2 hours.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Document the findings in the chart
B. Reassess the patient in 30 minutes
C. Perform a focused assessment and compare with baseline
data
D. Administer the prescribed PRN pain medication
Correct Answer:
C
Detailed Rationale:
The nurse must first assess because the cues suggest possible
clinical deterioration. A focused assessment helps determine
the cause of instability and guides timely intervention. This
reflects the first step of clinical judgment: recognize and
analyze cues.
Incorrect Option Analysis:
, • A. Document the findings in the chart — Incorrect
because documentation should follow assessment and
appropriate action.
o Misconception: Charting alone is enough.
o Safety risk: Delays intervention for possible shock or
bleeding.
• B. Reassess the patient in 30 minutes — Incorrect
because the findings are abnormal and urgent.
o Misconception: Waiting is acceptable when the
patient is “still awake.”
o Safety risk: Missed early deterioration.
• D. Administer the prescribed PRN pain medication —
Incorrect because pain medication does not address
hemodynamic instability.
o Misconception: Treating discomfort is the priority
over abnormal vital signs.
o Safety risk: May worsen hypotension or mask
worsening status.
Nursing Process Linkage:
Assessment
NCJMM Competency:
Recognize Cues, Analyze Cues
, Difficulty Level:
Difficult
Bloom’s Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Prioritize assessment when findings suggest acute patient
deterioration.
2) MCQ
Clinical Scenario:
An older adult admitted to the medical-surgical unit says, “I
want my daughter present when you explain anything to me,
and I hear better if I wear my hearing aid.”
Question Stem:
Which action best reflects patient-centered care?
Answer Options:
A. Provide teaching quickly while the patient is alone
B. Give printed materials and leave the room
C. Include the daughter and ensure the hearing aid is in place
before teaching
D. Tell the patient to ask questions after discharge
