Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Clinical Scenario:
A 69-year-old patient is 6 hours post–abdominal surgery. The
nurse notes that the patient becomes dizzy when standing, has
a heart rate of 118/min, blood pressure of 86/50 mm Hg, and
pale skin.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage the patient to drink more fluids
B. Assist the patient back to bed and reassess vital signs
immediately
C. Document the findings and continue with the next patient
D. Give the prescribed pain medication to promote rest
Correct Answer:
B. Assist the patient back to bed and reassess vital signs
immediately
Detailed Rationale:
The patient shows cues of possible orthostatic hypotension or
hypovolemia, which increases the risk for falls and impaired
perfusion. The nurse should act immediately to protect the
patient, then reassess and escalate if needed. This reflects early
recognition of deterioration and patient safety.
,Incorrect Option Analysis:
• A: Incorrect. Fluids may help later, but this does not
address the immediate safety risk. Misconception:
treating the symptom instead of the unstable condition.
Risk: fall or shock progression.
• C: Incorrect. Delaying action ignores a potentially unstable
patient. Misconception: documentation can replace
intervention. Risk: missed deterioration.
• D: Incorrect. Pain medication could worsen hypotension.
Misconception: assuming rest is the priority. Risk:
worsening hemodynamic instability.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies: Recognize Cues, Take Action
Difficulty: Moderate
Bloom’s Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Prioritize immediate nursing response
to cues of possible postoperative hemodynamic instability.
2) MCQ
Clinical Scenario:
A staff nurse is asked to update a wound-care practice on the
unit.
, Question Stem:
Which source best supports evidence-based nursing care?
Answer Options:
A. A colleague’s preferred dressing method
B. An outdated textbook used in school
C. A single patient’s positive outcome with a product
D. A current clinical practice guideline supported by research
Correct Answer:
D. A current clinical practice guideline supported by research
Detailed Rationale:
Evidence-based practice relies on the best current research
evidence, clinical expertise, and patient values. A guideline
synthesizes current research into a usable recommendation
and is stronger than personal opinion or isolated experience.
Incorrect Option Analysis:
• A: Incorrect. Colleague preference is not evidence.
Misconception: “experienced” means best. Risk:
inconsistent care.
• B: Incorrect. Old references may no longer reflect current
evidence. Misconception: any textbook is automatically
current. Risk: outdated practice.
• C: Incorrect. One case cannot establish a general standard.
Misconception: anecdote equals evidence. Risk: unreliable
care decisions.