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 admitted adult patient on a medical-surgical unit
stands up after a bath and says, “I feel lightheaded.” The nurse
notes pallor, a pulse of 122/min, and a blood pressure of 88/54
mm Hg.
Question Stem:
What is the nurse’s best initial action?
Answer Options:
A. Document the report and reassess later
B. Assist the patient to sit or lie down and reassess vital signs
C. Encourage the patient to walk slowly to improve circulation
D. Ask the patient to finish the bath before returning to bed
Correct Answer:
B
Detailed Rationale:
The patient shows cues of possible orthostatic intolerance or
hemodynamic instability. The safest first action is to prevent
injury, support perfusion, and reassess the patient immediately.
This reflects clinical judgment by recognizing cues and taking
protective action.
Incorrect Option Analysis:
• A. Incorrect.
, o Why: Delaying assessment ignores a possible acute
change.
o Misconception: Thinking dizziness after activity is
always harmless.
o Safety risk: Falls or delayed recognition of
shock/hypovolemia.
• C. Incorrect.
o Why: Ambulation could worsen symptoms.
o Misconception: Movement always improves
lightheadedness.
o Safety risk: Syncope and injury.
• D. Incorrect.
o Why: The patient should not continue activity until
stabilized.
o Misconception: Finishing a task is more important
than assessing symptoms.
o Safety risk: Deterioration and fall risk.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Take Action
Difficulty Level:
Moderate
, Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify the nurse’s priority response to cues of acute
hemodynamic change.
2) MCQ
Clinical Scenario:
A nurse teaches a patient how to use an incentive spirometer
after abdominal surgery.
Question Stem:
Which statement by the patient best demonstrates evaluation
of learning?
Answer Options:
A. “I will use this device every hour while I am awake.”
B. “I should use the spirometer only if I feel short of breath.”
C. “The spirometer will keep me from having pain.”
D. “I do not need to use it once I am walking.”
Correct Answer:
A
Detailed Rationale:
Evaluation means determining whether the teaching goal was
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 admitted adult patient on a medical-surgical unit
stands up after a bath and says, “I feel lightheaded.” The nurse
notes pallor, a pulse of 122/min, and a blood pressure of 88/54
mm Hg.
Question Stem:
What is the nurse’s best initial action?
Answer Options:
A. Document the report and reassess later
B. Assist the patient to sit or lie down and reassess vital signs
C. Encourage the patient to walk slowly to improve circulation
D. Ask the patient to finish the bath before returning to bed
Correct Answer:
B
Detailed Rationale:
The patient shows cues of possible orthostatic intolerance or
hemodynamic instability. The safest first action is to prevent
injury, support perfusion, and reassess the patient immediately.
This reflects clinical judgment by recognizing cues and taking
protective action.
Incorrect Option Analysis:
• A. Incorrect.
, o Why: Delaying assessment ignores a possible acute
change.
o Misconception: Thinking dizziness after activity is
always harmless.
o Safety risk: Falls or delayed recognition of
shock/hypovolemia.
• C. Incorrect.
o Why: Ambulation could worsen symptoms.
o Misconception: Movement always improves
lightheadedness.
o Safety risk: Syncope and injury.
• D. Incorrect.
o Why: The patient should not continue activity until
stabilized.
o Misconception: Finishing a task is more important
than assessing symptoms.
o Safety risk: Deterioration and fall risk.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Take Action
Difficulty Level:
Moderate
, Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify the nurse’s priority response to cues of acute
hemodynamic change.
2) MCQ
Clinical Scenario:
A nurse teaches a patient how to use an incentive spirometer
after abdominal surgery.
Question Stem:
Which statement by the patient best demonstrates evaluation
of learning?
Answer Options:
A. “I will use this device every hour while I am awake.”
B. “I should use the spirometer only if I feel short of breath.”
C. “The spirometer will keep me from having pain.”
D. “I do not need to use it once I am walking.”
Correct Answer:
A
Detailed Rationale:
Evaluation means determining whether the teaching goal was
