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 says, “I feel faint,” while sitting in a
chair. The nurse notes HR 118/min, BP 88/54 mm Hg, and cool,
pale skin.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Recheck the blood pressure in 30 minutes
B. Obtain a full pain assessment
C. Activate the rapid response system and stay with the patient
D. Document the findings and notify the charge nurse at end of
shift
Correct Answer:
C
Detailed Rationale:
The patient shows signs of acute hemodynamic instability,
which may indicate shock, bleeding, or another life-threatening
deterioration. The nurse should immediately call for assistance
and remain with the patient while initiating emergency
response steps. This follows priority thinking and patient safety
principles.
Incorrect Option Analysis:
A. Incorrect because delay could worsen perfusion.
Misconception: abnormal vital signs can be “watched.” Risk:
,progression to collapse or organ damage.
B. Incorrect because pain assessment is not the priority over
instability. Misconception: all symptoms require equal
attention. Risk: delayed treatment of shock.
D. Incorrect because this is not routine documentation.
Misconception: charting can come before action. Risk: missed
rescue opportunity.
Nursing Process Linkage: Implementation
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Prioritize Hypotheses, Take Action
Difficulty: Moderate
Bloom’s Level: Apply
NCLEX Client Needs: Physiological Adaptation
Key Learning Objective: Identify the priority response to signs
of acute patient deterioration.
2) SATA
Clinical Scenario:
A nurse is caring for a new admission who speaks limited
English and has a strong preference for family involvement in
decisions.
Question Stem:
Which nursing actions demonstrate patient-centered care?
Select all that apply.
, Answer Options:
A. Ask the patient how they prefer to be addressed
B. Schedule teaching when the patient is most alert
C. Make care decisions without the patient to reduce stress
D. Use teach-back to confirm understanding
E. Ask about cultural or dietary preferences that may affect
care
Correct Answers:
A, B, D, E
Detailed Rationale:
Patient-centered care respects the person’s values,
preferences, language needs, and readiness to learn. It also
uses teach-back to confirm understanding and supports
individualized planning.
Incorrect Option Analysis:
C. Incorrect because excluding the patient undermines
autonomy. Misconception: family involvement replaces patient
involvement. Risk: poor adherence and ethical concerns.
Nursing Process Linkage: Assessment, Planning,
Implementation
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Generate Solutions
Difficulty: Easy
Bloom’s Level: Understand
NCLEX Client Needs: Psychosocial Integrity
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 says, “I feel faint,” while sitting in a
chair. The nurse notes HR 118/min, BP 88/54 mm Hg, and cool,
pale skin.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Recheck the blood pressure in 30 minutes
B. Obtain a full pain assessment
C. Activate the rapid response system and stay with the patient
D. Document the findings and notify the charge nurse at end of
shift
Correct Answer:
C
Detailed Rationale:
The patient shows signs of acute hemodynamic instability,
which may indicate shock, bleeding, or another life-threatening
deterioration. The nurse should immediately call for assistance
and remain with the patient while initiating emergency
response steps. This follows priority thinking and patient safety
principles.
Incorrect Option Analysis:
A. Incorrect because delay could worsen perfusion.
Misconception: abnormal vital signs can be “watched.” Risk:
,progression to collapse or organ damage.
B. Incorrect because pain assessment is not the priority over
instability. Misconception: all symptoms require equal
attention. Risk: delayed treatment of shock.
D. Incorrect because this is not routine documentation.
Misconception: charting can come before action. Risk: missed
rescue opportunity.
Nursing Process Linkage: Implementation
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Prioritize Hypotheses, Take Action
Difficulty: Moderate
Bloom’s Level: Apply
NCLEX Client Needs: Physiological Adaptation
Key Learning Objective: Identify the priority response to signs
of acute patient deterioration.
2) SATA
Clinical Scenario:
A nurse is caring for a new admission who speaks limited
English and has a strong preference for family involvement in
decisions.
Question Stem:
Which nursing actions demonstrate patient-centered care?
Select all that apply.
, Answer Options:
A. Ask the patient how they prefer to be addressed
B. Schedule teaching when the patient is most alert
C. Make care decisions without the patient to reduce stress
D. Use teach-back to confirm understanding
E. Ask about cultural or dietary preferences that may affect
care
Correct Answers:
A, B, D, E
Detailed Rationale:
Patient-centered care respects the person’s values,
preferences, language needs, and readiness to learn. It also
uses teach-back to confirm understanding and supports
individualized planning.
Incorrect Option Analysis:
C. Incorrect because excluding the patient undermines
autonomy. Misconception: family involvement replaces patient
involvement. Risk: poor adherence and ethical concerns.
Nursing Process Linkage: Assessment, Planning,
Implementation
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Generate Solutions
Difficulty: Easy
Bloom’s Level: Understand
NCLEX Client Needs: Psychosocial Integrity
