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 nurse is caring for a patient 6 hours after abdominal surgery.
The patient reports increasing abdominal pain, feels dizzy when
turning, and the surgical dressing has new bright-red drainage.
Question Stem
What is the nurse’s priority action?
Answer Options
A. Administer the prescribed opioid analgesic
B. Reassess the patient in 30 minutes
C. Inspect the dressing and quantify the drainage
D. Encourage the patient to use the incentive spirometer
Correct Answer
C. Inspect the dressing and quantify the drainage
Detailed Rationale
New bright-red drainage with dizziness after surgery suggests
possible bleeding and decreased circulating volume. The nurse
must recognize cues of deterioration and assess the likely
source immediately. Quantifying drainage helps determine
severity and guides escalation. Pain control and pulmonary
hygiene are important, but bleeding is the priority safety
concern.
,Incorrect Option Analysis
• A. Administer the prescribed opioid analgesic — Incorrect
because pain relief does not address possible hemorrhage.
Misconception: Thinking pain is the main problem
because it is the stated complaint.
Risk: Delayed recognition of postoperative bleeding.
• B. Reassess the patient in 30 minutes — Incorrect
because the situation requires immediate assessment.
Misconception: Assuming symptoms are stable enough to
watch.
Risk: Progression to shock.
• D. Encourage the patient to use the incentive spirometer
— Incorrect because respiratory prevention is not the
immediate priority.
Misconception: Prioritizing routine postoperative care
over deterioration.
Risk: Missed hemorrhage.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues, Analyze Cues, Prioritize Hypotheses, Take
Action
Difficulty Level
Difficult
, Bloom’s Cognitive Level
Analyze
NCLEX Client Needs Category
Physiological Adaptation
Key Learning Objective
Identify priority postoperative assessment when signs of
possible hemorrhage are present.
2) SATA
Clinical Scenario
A nurse is reviewing infection prevention measures with a
patient who has a central venous access device.
Question Stem
Which instructions should the nurse include? Select all that
apply.
Answer Options
A. Perform hand hygiene before any contact with the catheter
B. Scrub the catheter hub before access
C. Remove the dressing daily so the site can “air out”
D. Report fever, chills, or redness at the insertion site
E. Use clean gloves for catheter insertion
F. Keep the catheter in place only as long as it is needed
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
,1) MCQ
Clinical Scenario
A nurse is caring for a patient 6 hours after abdominal surgery.
The patient reports increasing abdominal pain, feels dizzy when
turning, and the surgical dressing has new bright-red drainage.
Question Stem
What is the nurse’s priority action?
Answer Options
A. Administer the prescribed opioid analgesic
B. Reassess the patient in 30 minutes
C. Inspect the dressing and quantify the drainage
D. Encourage the patient to use the incentive spirometer
Correct Answer
C. Inspect the dressing and quantify the drainage
Detailed Rationale
New bright-red drainage with dizziness after surgery suggests
possible bleeding and decreased circulating volume. The nurse
must recognize cues of deterioration and assess the likely
source immediately. Quantifying drainage helps determine
severity and guides escalation. Pain control and pulmonary
hygiene are important, but bleeding is the priority safety
concern.
,Incorrect Option Analysis
• A. Administer the prescribed opioid analgesic — Incorrect
because pain relief does not address possible hemorrhage.
Misconception: Thinking pain is the main problem
because it is the stated complaint.
Risk: Delayed recognition of postoperative bleeding.
• B. Reassess the patient in 30 minutes — Incorrect
because the situation requires immediate assessment.
Misconception: Assuming symptoms are stable enough to
watch.
Risk: Progression to shock.
• D. Encourage the patient to use the incentive spirometer
— Incorrect because respiratory prevention is not the
immediate priority.
Misconception: Prioritizing routine postoperative care
over deterioration.
Risk: Missed hemorrhage.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues, Analyze Cues, Prioritize Hypotheses, Take
Action
Difficulty Level
Difficult
, Bloom’s Cognitive Level
Analyze
NCLEX Client Needs Category
Physiological Adaptation
Key Learning Objective
Identify priority postoperative assessment when signs of
possible hemorrhage are present.
2) SATA
Clinical Scenario
A nurse is reviewing infection prevention measures with a
patient who has a central venous access device.
Question Stem
Which instructions should the nurse include? Select all that
apply.
Answer Options
A. Perform hand hygiene before any contact with the catheter
B. Scrub the catheter hub before access
C. Remove the dressing daily so the site can “air out”
D. Report fever, chills, or redness at the insertion site
E. Use clean gloves for catheter insertion
F. Keep the catheter in place only as long as it is needed
