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 on a medical-surgical unit says, “I feel
dizzy when I stand up.” The nurse finds the patient pale, with a
blood pressure of 88/54 mm Hg and a pulse of 112 beats/min.
Question Stem:
What is the nurse’s best initial action?
Answer Options:
A. Assist the patient back to bed and reassess vital signs
B. Encourage the patient to walk slowly to improve circulation
C. Offer oral fluids and return in 1 hour
D. Document the finding as expected after surgery
Correct Answer:
A
Detailed Rationale:
The patient shows signs of possible orthostatic hypotension or
decreased circulating volume, and the first priority is safety.
Assisting the patient back to bed reduces fall risk and allows
immediate reassessment. The nurse should then evaluate for
contributing factors such as blood loss, dehydration, or
medication effects.
Incorrect Option Analysis:
• B: Incorrect. Ambulation while symptomatic increases fall
risk. Misconception: dizziness is “normal” after surgery.
Risk: injury from a fall.
, • C: Incorrect. Oral fluids may help if appropriate, but safety
and immediate reassessment come first. Risk: delayed
response to potential deterioration.
• D: Incorrect. This is not an expected finding to ignore. Risk:
missed hypotension and delayed intervention.
Nursing Process Linkage:
Assessment
NCJMM Competencies:
Recognize Cues; Take Action
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Reduction of Risk Potential
Key Learning Objective:
Prioritize immediate safety and recognize early signs of
hemodynamic instability.
2) SATA
Clinical Scenario:
A patient with limited English proficiency is admitted for a
planned procedure. The patient’s adult daughter is present and
begins answering every question for the patient.
, Question Stem:
Which nursing actions support patient-centered care? Select all
that apply.
Answer Options:
A. Ask the patient about personal preferences and goals for
care
B. Ask the daughter to answer all questions to save time
C. Use a certified interpreter if language assistance is needed
D. Use teach-back to confirm understanding
E. Invite family participation only if the patient agrees
Correct Answers:
A, C, D, E
Detailed Rationale:
Patient-centered care requires respect for the patient’s
autonomy, communication needs, and preferences. The nurse
should speak directly to the patient, use interpreter services
when needed, and use teach-back to confirm understanding.
Family involvement is appropriate when the patient wants it.
Incorrect Option Analysis:
• B: Incorrect. Family may support care, but should not
replace the patient’s voice. Misconception: family can
automatically interpret. Risk: inaccurate communication,
loss of autonomy, consent problems.
Nursing Process Linkage:
Assessment and Planning
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 on a medical-surgical unit says, “I feel
dizzy when I stand up.” The nurse finds the patient pale, with a
blood pressure of 88/54 mm Hg and a pulse of 112 beats/min.
Question Stem:
What is the nurse’s best initial action?
Answer Options:
A. Assist the patient back to bed and reassess vital signs
B. Encourage the patient to walk slowly to improve circulation
C. Offer oral fluids and return in 1 hour
D. Document the finding as expected after surgery
Correct Answer:
A
Detailed Rationale:
The patient shows signs of possible orthostatic hypotension or
decreased circulating volume, and the first priority is safety.
Assisting the patient back to bed reduces fall risk and allows
immediate reassessment. The nurse should then evaluate for
contributing factors such as blood loss, dehydration, or
medication effects.
Incorrect Option Analysis:
• B: Incorrect. Ambulation while symptomatic increases fall
risk. Misconception: dizziness is “normal” after surgery.
Risk: injury from a fall.
, • C: Incorrect. Oral fluids may help if appropriate, but safety
and immediate reassessment come first. Risk: delayed
response to potential deterioration.
• D: Incorrect. This is not an expected finding to ignore. Risk:
missed hypotension and delayed intervention.
Nursing Process Linkage:
Assessment
NCJMM Competencies:
Recognize Cues; Take Action
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Reduction of Risk Potential
Key Learning Objective:
Prioritize immediate safety and recognize early signs of
hemodynamic instability.
2) SATA
Clinical Scenario:
A patient with limited English proficiency is admitted for a
planned procedure. The patient’s adult daughter is present and
begins answering every question for the patient.
, Question Stem:
Which nursing actions support patient-centered care? Select all
that apply.
Answer Options:
A. Ask the patient about personal preferences and goals for
care
B. Ask the daughter to answer all questions to save time
C. Use a certified interpreter if language assistance is needed
D. Use teach-back to confirm understanding
E. Invite family participation only if the patient agrees
Correct Answers:
A, C, D, E
Detailed Rationale:
Patient-centered care requires respect for the patient’s
autonomy, communication needs, and preferences. The nurse
should speak directly to the patient, use interpreter services
when needed, and use teach-back to confirm understanding.
Family involvement is appropriate when the patient wants it.
Incorrect Option Analysis:
• B: Incorrect. Family may support care, but should not
replace the patient’s voice. Misconception: family can
automatically interpret. Risk: inaccurate communication,
loss of autonomy, consent problems.
Nursing Process Linkage:
Assessment and Planning
