Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Question Number and Type: 1. MCQ
Clinical Scenario:
A nurse receives shift report on four adult medical-surgical
patients.
Question Stem:
Which patient should the nurse assess first?
Answer Options:
A. A patient who reports incisional pain rated 6/10 after
ambulating
B. A patient who is asking for discharge teaching materials
C. A patient whose blood pressure is 98/62 mm Hg and says, “I
feel a little tired”
D. A patient whose oxygen saturation dropped from 96% to
88% and who is now confused
Correct Answer:
D
Detailed Rationale:
The patient with a decreasing oxygen saturation and new
confusion shows cues of possible acute deterioration.
Oxygenation is a priority because inadequate oxygen delivery
can rapidly affect brain and organ function. This reflects early
recognition of instability and immediate action in clinical
judgment.
,Incorrect Option Analysis:
• A: Pain requires treatment, but it is not the first priority
over impaired oxygenation.
o Common misconception: Assuming all pain
complaints are urgent.
o Safety risk: Delaying assessment of hypoxia.
• B: Discharge teaching is important but not urgent.
o Common misconception: Prioritizing tasks based on
workflow instead of patient status.
o Safety risk: Failing to identify life-threatening decline.
• C: Mild hypotension and fatigue require assessment, but
this is less urgent than acute hypoxia with confusion.
o Common misconception: Treating subtle vital sign
changes as more urgent than neurologic and
respiratory compromise.
o Safety risk: Delayed intervention for worsening
hypoxemia.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Prioritize Hypotheses
Difficulty Level:
Moderate
, Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Prioritize the patient with the most urgent physiologic
instability.
2) MCQ
Question Number and Type: 2. MCQ
Clinical Scenario:
A newly admitted patient reports dizziness when standing.
Question Stem:
Which finding is an example of subjective data?
Answer Options:
A. Blood pressure decreases from 124/78 to 98/60 mm Hg
when standing
B. The patient says, “I feel lightheaded when I get up”
C. Pulse increases from 84 to 110 beats/min
D. The nurse observes unsteady gait while walking to the
bathroom
Correct Answer:
B