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 newly licensed nurse is caring for a postoperative patient on
the medical-surgical unit. The patient states, “I feel dizzy when I
sit up,” and the blood pressure drops from 128/78 mm Hg lying
down to 96/60 mm Hg standing.
Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage the patient to walk to improve circulation
B. Assist the patient back to bed and reassess vital signs
C. Document the finding as expected after surgery
D. Notify physical therapy to evaluate mobility
Correct Answer:
B. Assist the patient back to bed and reassess vital signs
Detailed Rationale:
Orthostatic hypotension places the patient at immediate risk
for falls and reduced cerebral perfusion. The priority is to
ensure safety, return the patient to a safe position, and
reassess for ongoing instability. This reflects clinical judgment
by recognizing a cue of deterioration and taking immediate
action to prevent harm.
Incorrect Option Analysis:
• A. Incorrect: Walking increases the risk of syncope and
injury.
, Common misconception: Activity is always beneficial after
surgery.
Safety risk: Fall, injury, or loss of consciousness.
• C. Incorrect: This is not expected and should not be
dismissed.
Common misconception: Postoperative dizziness is
automatically normal.
Safety risk: Missed hypovolemia, bleeding, or medication
effect.
• D. Incorrect: Physical therapy is not the immediate
priority.
Common misconception: Mobility concerns always
require consult first.
Safety risk: Delayed response to an acute safety issue.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Analyze Cues, Take Action
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective:
Prioritize immediate nursing actions when a patient
demonstrates orthostatic hypotension and fall risk.
, 2. MCQ
Clinical Scenario:
A nurse on a surgical unit is reviewing central line care
practices. The unit wants to reduce bloodstream infections.
Stem:
Which intervention best reflects evidence-based nursing care?
Answer Options:
A. Changing the central line dressing only when it looks soiled
B. Cleaning the insertion site with chlorhexidine before dressing
changes
C. Using sterile gloves only if the patient has a fever
D. Flushing the line with normal saline after every medication
Correct Answer:
B. Cleaning the insertion site with chlorhexidine before
dressing changes
Detailed Rationale:
Chlorhexidine skin antisepsis is an evidence-supported infection
prevention measure for central line maintenance. It reduces
microbial colonization and bloodstream infection risk. This
reflects evidence-based practice by using the best available
research to guide care.
Incorrect Option Analysis:
• A. Incorrect: Dressings require scheduled care and
assessment, not only changes when visibly soiled.
Misconception: Visual appearance is sufficient for line
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,1. MCQ
Clinical Scenario:
A newly licensed nurse is caring for a postoperative patient on
the medical-surgical unit. The patient states, “I feel dizzy when I
sit up,” and the blood pressure drops from 128/78 mm Hg lying
down to 96/60 mm Hg standing.
Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage the patient to walk to improve circulation
B. Assist the patient back to bed and reassess vital signs
C. Document the finding as expected after surgery
D. Notify physical therapy to evaluate mobility
Correct Answer:
B. Assist the patient back to bed and reassess vital signs
Detailed Rationale:
Orthostatic hypotension places the patient at immediate risk
for falls and reduced cerebral perfusion. The priority is to
ensure safety, return the patient to a safe position, and
reassess for ongoing instability. This reflects clinical judgment
by recognizing a cue of deterioration and taking immediate
action to prevent harm.
Incorrect Option Analysis:
• A. Incorrect: Walking increases the risk of syncope and
injury.
, Common misconception: Activity is always beneficial after
surgery.
Safety risk: Fall, injury, or loss of consciousness.
• C. Incorrect: This is not expected and should not be
dismissed.
Common misconception: Postoperative dizziness is
automatically normal.
Safety risk: Missed hypovolemia, bleeding, or medication
effect.
• D. Incorrect: Physical therapy is not the immediate
priority.
Common misconception: Mobility concerns always
require consult first.
Safety risk: Delayed response to an acute safety issue.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Analyze Cues, Take Action
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective:
Prioritize immediate nursing actions when a patient
demonstrates orthostatic hypotension and fall risk.
, 2. MCQ
Clinical Scenario:
A nurse on a surgical unit is reviewing central line care
practices. The unit wants to reduce bloodstream infections.
Stem:
Which intervention best reflects evidence-based nursing care?
Answer Options:
A. Changing the central line dressing only when it looks soiled
B. Cleaning the insertion site with chlorhexidine before dressing
changes
C. Using sterile gloves only if the patient has a fever
D. Flushing the line with normal saline after every medication
Correct Answer:
B. Cleaning the insertion site with chlorhexidine before
dressing changes
Detailed Rationale:
Chlorhexidine skin antisepsis is an evidence-supported infection
prevention measure for central line maintenance. It reduces
microbial colonization and bloodstream infection risk. This
reflects evidence-based practice by using the best available
research to guide care.
Incorrect Option Analysis:
• A. Incorrect: Dressings require scheduled care and
assessment, not only changes when visibly soiled.
Misconception: Visual appearance is sufficient for line
