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 new graduate nurse is caring for a patient admitted with
dehydration and weakness. The patient is dizzy when standing,
,and the nurse notices the blood pressure dropped from 128/76
mm Hg to 94/60 mm Hg.
Question Stem:
Which nursing action best demonstrates clinical judgment in
this situation?
Answer Options:
A. Document the blood pressure change in the chart at the end
of the shift
B. Assist the patient to a chair and continue routine care
C. Reassess vital signs, assess orthostatic symptoms, and notify
the provider if the findings persist
D. Ask the nursing assistant to encourage the patient to drink
more fluids
Correct Answer:
C
Detailed Rationale:
Clinical judgment involves recognizing cues, analyzing their
significance, and acting to prevent harm. The blood pressure
drop with dizziness suggests orthostatic hypotension, which
increases fall risk and may reflect volume depletion. The nurse
should reassess, confirm the findings, and escalate
appropriately.
Incorrect Option Analysis:
• A: Incorrect. Delayed documentation does not protect the
patient from immediate risk.
, o Misconception: Charting equals action.
o Risk: Missed deterioration and preventable falls.
• B: Incorrect. Sitting the patient down may reduce
immediate injury risk, but it does not address the
abnormal findings.
o Misconception: Comfort alone is enough.
o Risk: Ongoing instability may go unrecognized.
• D: Incorrect. Fluids may help, but delegation without
assessment is unsafe.
o Misconception: Any task related to the problem is
appropriate.
o Risk: Failure to identify a potentially serious cause of
hypotension.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Analyze Cues, Take Action
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify the immediate nursing
response to abnormal hemodynamic cues.
2) SATA
, Clinical Scenario:
A hospitalized older adult is at risk for falls and asks for help to
the bathroom. The room is cluttered, and the call light is out of
reach.
Question Stem:
Which actions support patient safety outcomes? Select all that
apply.
Answer Options:
A. Place the call light within reach
B. Keep the bed in the lowest position
C. Raise all four side rails to prevent falls
D. Ensure nonskid footwear is available
E. Remove clutter from the walking path
Correct Answer:
A, B, D, E
Detailed Rationale:
These are standard fall-prevention interventions. They reduce
environmental hazards and support safe mobility. Side rails are
not a substitute for supervision and can increase injury risk if
used improperly.
Incorrect Option Analysis:
• C: Incorrect. All four side rails can create a restraint-like
situation and increase climbing/fall risk.
o Misconception: More barriers automatically mean
more safety.
Surgical Nursing
Making Connections to Practice
3rd Edition
• Author(s)Janice Hoffman; Nancy
Sullivan
• Print ISBN: 9781719647366
TEST BANK
1) MCQ
Clinical Scenario:
A new graduate nurse is caring for a patient admitted with
dehydration and weakness. The patient is dizzy when standing,
,and the nurse notices the blood pressure dropped from 128/76
mm Hg to 94/60 mm Hg.
Question Stem:
Which nursing action best demonstrates clinical judgment in
this situation?
Answer Options:
A. Document the blood pressure change in the chart at the end
of the shift
B. Assist the patient to a chair and continue routine care
C. Reassess vital signs, assess orthostatic symptoms, and notify
the provider if the findings persist
D. Ask the nursing assistant to encourage the patient to drink
more fluids
Correct Answer:
C
Detailed Rationale:
Clinical judgment involves recognizing cues, analyzing their
significance, and acting to prevent harm. The blood pressure
drop with dizziness suggests orthostatic hypotension, which
increases fall risk and may reflect volume depletion. The nurse
should reassess, confirm the findings, and escalate
appropriately.
Incorrect Option Analysis:
• A: Incorrect. Delayed documentation does not protect the
patient from immediate risk.
, o Misconception: Charting equals action.
o Risk: Missed deterioration and preventable falls.
• B: Incorrect. Sitting the patient down may reduce
immediate injury risk, but it does not address the
abnormal findings.
o Misconception: Comfort alone is enough.
o Risk: Ongoing instability may go unrecognized.
• D: Incorrect. Fluids may help, but delegation without
assessment is unsafe.
o Misconception: Any task related to the problem is
appropriate.
o Risk: Failure to identify a potentially serious cause of
hypotension.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Analyze Cues, Take Action
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify the immediate nursing
response to abnormal hemodynamic cues.
2) SATA
, Clinical Scenario:
A hospitalized older adult is at risk for falls and asks for help to
the bathroom. The room is cluttered, and the call light is out of
reach.
Question Stem:
Which actions support patient safety outcomes? Select all that
apply.
Answer Options:
A. Place the call light within reach
B. Keep the bed in the lowest position
C. Raise all four side rails to prevent falls
D. Ensure nonskid footwear is available
E. Remove clutter from the walking path
Correct Answer:
A, B, D, E
Detailed Rationale:
These are standard fall-prevention interventions. They reduce
environmental hazards and support safe mobility. Side rails are
not a substitute for supervision and can increase injury risk if
used improperly.
Incorrect Option Analysis:
• C: Incorrect. All four side rails can create a restraint-like
situation and increase climbing/fall risk.
o Misconception: More barriers automatically mean
more safety.
