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 suddenly says, “I feel
dizzy,” while standing at the bedside. The blood pressure is
86/50 mm Hg, heart rate 118/min, and skin is cool and clammy.
Stem: What is the nurse’s best first action?
Answer Options:
A. Document the complaint and recheck in 30 minutes
B. Notify the surgeon immediately
C. Assist the patient back to bed and assess vital signs and level
of consciousness
D. Offer oral fluids and encourage slow deep breathing
Correct Answer: C
Detailed Rationale:
The priority is to recognize and assess cues suggesting
decreased perfusion and possible hemodynamic instability.
Assisting the patient back to bed prevents injury, and
reassessing vital signs and mentation helps determine severity
and next actions. This is the safest first step in the nursing
process.
Incorrect Option Analysis:
• A: Incorrect because delaying assessment risks missing
worsening shock or syncope. Misconception: “wait and
see.” Risk: falls, poor perfusion.
• B: Incorrect as a first action because provider notification
should follow immediate bedside assessment.
, Misconception: calling first always equals priority. Risk:
delayed recognition of instability.
• D: Incorrect because oral fluids and breathing exercises do
not address possible acute hypoperfusion. Misconception:
all dizziness is benign. Risk: aspiration or collapse.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues, Take Action
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify the first nursing action when
acute deterioration is suspected.
2) SATA
Clinical Scenario: A nurse is revising care for a patient at high
risk for pressure injury.
Stem: Which actions reflect evidence-based nursing care?
Select all that apply.
Answer Options:
A. Use the facility’s current pressure injury prevention guideline
B. Base the plan only on what worked for the last patient
C. Combine current research evidence, clinical expertise, and
patient preferences
D. Evaluate whether the intervention is reducing skin
breakdown
, E. Follow routine practice even if the patient’s condition
changes
Correct Answer: A, C, D
Detailed Rationale:
Evidence-based care integrates the best available research, the
nurse’s clinical expertise, and the patient’s values/preferences,
then evaluates outcomes. Current guidelines and outcome
evaluation are central to safe, effective care.
Incorrect Option Analysis:
• B: Incorrect because one patient’s response is not
evidence. Misconception: anecdote equals proof. Risk:
ineffective prevention.
• E: Incorrect because care must change with patient risk
and reassessment. Misconception: routine equals quality.
Risk: preventable injury.
Nursing Process Linkage: Planning, Evaluation
NCJMM Competencies: Analyze Cues, Generate Solutions,
Evaluate Outcomes
Difficulty Level: Moderate
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Safety and Infection Control
Key Learning Objective: Distinguish evidence-based practice
from routine-based practice.
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 suddenly says, “I feel
dizzy,” while standing at the bedside. The blood pressure is
86/50 mm Hg, heart rate 118/min, and skin is cool and clammy.
Stem: What is the nurse’s best first action?
Answer Options:
A. Document the complaint and recheck in 30 minutes
B. Notify the surgeon immediately
C. Assist the patient back to bed and assess vital signs and level
of consciousness
D. Offer oral fluids and encourage slow deep breathing
Correct Answer: C
Detailed Rationale:
The priority is to recognize and assess cues suggesting
decreased perfusion and possible hemodynamic instability.
Assisting the patient back to bed prevents injury, and
reassessing vital signs and mentation helps determine severity
and next actions. This is the safest first step in the nursing
process.
Incorrect Option Analysis:
• A: Incorrect because delaying assessment risks missing
worsening shock or syncope. Misconception: “wait and
see.” Risk: falls, poor perfusion.
• B: Incorrect as a first action because provider notification
should follow immediate bedside assessment.
, Misconception: calling first always equals priority. Risk:
delayed recognition of instability.
• D: Incorrect because oral fluids and breathing exercises do
not address possible acute hypoperfusion. Misconception:
all dizziness is benign. Risk: aspiration or collapse.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues, Take Action
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify the first nursing action when
acute deterioration is suspected.
2) SATA
Clinical Scenario: A nurse is revising care for a patient at high
risk for pressure injury.
Stem: Which actions reflect evidence-based nursing care?
Select all that apply.
Answer Options:
A. Use the facility’s current pressure injury prevention guideline
B. Base the plan only on what worked for the last patient
C. Combine current research evidence, clinical expertise, and
patient preferences
D. Evaluate whether the intervention is reducing skin
breakdown
, E. Follow routine practice even if the patient’s condition
changes
Correct Answer: A, C, D
Detailed Rationale:
Evidence-based care integrates the best available research, the
nurse’s clinical expertise, and the patient’s values/preferences,
then evaluates outcomes. Current guidelines and outcome
evaluation are central to safe, effective care.
Incorrect Option Analysis:
• B: Incorrect because one patient’s response is not
evidence. Misconception: anecdote equals proof. Risk:
ineffective prevention.
• E: Incorrect because care must change with patient risk
and reassessment. Misconception: routine equals quality.
Risk: preventable injury.
Nursing Process Linkage: Planning, Evaluation
NCJMM Competencies: Analyze Cues, Generate Solutions,
Evaluate Outcomes
Difficulty Level: Moderate
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Safety and Infection Control
Key Learning Objective: Distinguish evidence-based practice
from routine-based practice.
