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 patient says, “I feel dizzy when I sit up.” The
nurse notes BP 88/54 mm Hg, pulse 118/min, and pale, cool
skin.
Question stem:
What is the nurse’s best first action?
Answer options:
A. Document the findings and reassess in 1 hour
B. Assist the patient back to bed and notify the provider
C. Encourage oral fluids and ambulate the patient slowly
D. Ask the UAP to obtain a set of vital signs
Correct answer:
B. Assist the patient back to bed and notify the provider
Detailed rationale:
The patient has cues of possible orthostatic hypotension and
decreased perfusion. The nurse should take action
immediately to prevent a fall and further deterioration, then
report the abnormal findings. This reflects clinical judgment:
recognize cues, analyze instability, act for safety.
Incorrect option analysis:
• A: Incorrect. Delaying action risks syncope, injury, and
worsening hypotension.
, • C: Incorrect. Oral fluids and ambulation are not
appropriate first steps in an unstable patient.
• D: Incorrect. A UAP may obtain vitals, but the nurse must
first respond to the unstable assessment findings.
Nursing process link: Implementation
NCJMM competencies: Recognize Cues, Analyze Cues, Take
Action
Difficulty: Moderate
Bloom’s level: Analyze
NCLEX client needs: Physiological Adaptation / Safety and
Infection Control
Key learning objective: Identify priority nursing action for signs
of hemodynamic instability.
2) MCQ
Clinical scenario:
A nurse is revising a unit practice for pressure injury prevention.
Some staff say, “We have always repositioned patients every 2
hours, so that is enough.”
Question stem:
Which action best reflects evidence-based nursing care?
Answer options:
A. Continue the 2-hour turning schedule for all patients without
changes
B. Review current evidence, skin risk factors, and patient
, preferences before updating the plan
C. Ask the charge nurse which turning schedule is easiest to
follow
D. Use the same wound care routine for every patient to reduce
variation
Correct answer:
B. Review current evidence, skin risk factors, and patient
preferences before updating the plan
Detailed rationale:
Evidence-based care combines best available research, clinical
expertise, and patient preferences. Pressure injury prevention
should be individualized based on risk, mobility, nutrition,
moisture, and device-related pressure.
Incorrect option analysis:
• A: Incorrect. A routine alone is not evidence-based if it
ignores patient-specific risk.
• C: Incorrect. Convenience is not the standard for evidence-
based practice.
• D: Incorrect. Standardizing care without assessment can
miss patient-specific needs and increase harm.
Nursing process link: Planning
NCJMM competencies: Analyze Cues, Generate Solutions
Difficulty: Moderate
Bloom’s level: Analyze
NCLEX client needs: Management of Care / Safety and Infection
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 patient says, “I feel dizzy when I sit up.” The
nurse notes BP 88/54 mm Hg, pulse 118/min, and pale, cool
skin.
Question stem:
What is the nurse’s best first action?
Answer options:
A. Document the findings and reassess in 1 hour
B. Assist the patient back to bed and notify the provider
C. Encourage oral fluids and ambulate the patient slowly
D. Ask the UAP to obtain a set of vital signs
Correct answer:
B. Assist the patient back to bed and notify the provider
Detailed rationale:
The patient has cues of possible orthostatic hypotension and
decreased perfusion. The nurse should take action
immediately to prevent a fall and further deterioration, then
report the abnormal findings. This reflects clinical judgment:
recognize cues, analyze instability, act for safety.
Incorrect option analysis:
• A: Incorrect. Delaying action risks syncope, injury, and
worsening hypotension.
, • C: Incorrect. Oral fluids and ambulation are not
appropriate first steps in an unstable patient.
• D: Incorrect. A UAP may obtain vitals, but the nurse must
first respond to the unstable assessment findings.
Nursing process link: Implementation
NCJMM competencies: Recognize Cues, Analyze Cues, Take
Action
Difficulty: Moderate
Bloom’s level: Analyze
NCLEX client needs: Physiological Adaptation / Safety and
Infection Control
Key learning objective: Identify priority nursing action for signs
of hemodynamic instability.
2) MCQ
Clinical scenario:
A nurse is revising a unit practice for pressure injury prevention.
Some staff say, “We have always repositioned patients every 2
hours, so that is enough.”
Question stem:
Which action best reflects evidence-based nursing care?
Answer options:
A. Continue the 2-hour turning schedule for all patients without
changes
B. Review current evidence, skin risk factors, and patient
, preferences before updating the plan
C. Ask the charge nurse which turning schedule is easiest to
follow
D. Use the same wound care routine for every patient to reduce
variation
Correct answer:
B. Review current evidence, skin risk factors, and patient
preferences before updating the plan
Detailed rationale:
Evidence-based care combines best available research, clinical
expertise, and patient preferences. Pressure injury prevention
should be individualized based on risk, mobility, nutrition,
moisture, and device-related pressure.
Incorrect option analysis:
• A: Incorrect. A routine alone is not evidence-based if it
ignores patient-specific risk.
• C: Incorrect. Convenience is not the standard for evidence-
based practice.
• D: Incorrect. Standardizing care without assessment can
miss patient-specific needs and increase harm.
Nursing process link: Planning
NCJMM competencies: Analyze Cues, Generate Solutions
Difficulty: Moderate
Bloom’s level: Analyze
NCLEX client needs: Management of Care / Safety and Infection
