Linton and Matteson's Medical-Surgical
Practical Nursing in Canada, 1st Edition
Authors:
Katherine Poser,Adrianne Dill Linton,Mary
Ann Matteson
TEST BANK.
Source: Linton and Matteson's Medical-Surgical Practical
Nursing in Canada
(Chapter used: Chapter 1 — Aspects of Medical-Surgical
Nursing)
1. (Standard — Single best answer)
A 72-year-old post-operative client is admitted after a
below-knee amputation. The PN receives the handover
, and notes the client is sleepy but arousable, RR 10/min,
SpO₂ 88% on room air, O₂ sat 95% earlier in PACU. Which
action should the PN perform first?
A. Reassess pain score and give PRN opioid.
B. Encourage deep breathing and coughing.
C. Apply supplemental oxygen and re-assess SpO₂.
D. Report change to the surgeon.
Answer: C. Apply supplemental oxygen and re-assess SpO₂.
Rationale: Hypoxemia (SpO₂ 88%) is an immediate physiologic
threat. The nurse’s first action is to restore adequate
oxygenation, then reassess and address causes. Reporting and
pain management follow stabilization.
Citation: Chapter 1 — Aspects of Medical-Surgical Nursing.
2. (Priority — First action)
During morning rounds, a client with chest pain reports
sudden palpitations and lightheadedness. Telemetry shows
new-onset ventricular tachycardia (VT) with a pulse of 42
bpm. What is the PN’s first action?
A. Prepare to administer IV amiodarone.
B. Call the rapid response team and stay with the client.
C. Take the client’s blood pressure and complete the ECG.
D. Place the client on oxygen and increase the IV fluid rate.
Answer: B. Call the rapid response team and stay with the
client.
Rationale: New symptomatic VT with bradycardia is unstable—
,immediate escalation (RRT/code) and continuous monitoring
while remaining with the client is priority. Medication and
diagnostics follow the team’s directives.
Citation: Chapter 1 — Aspects of Medical-Surgical Nursing.
3. (SATA — Select all that apply)
Which of the following actions are appropriate for safe
delegation of tasks to a nursing assistant (unregulated care
provider) for a stable medical-surgical client? (Select all
that apply.)
A. Ask the assistant to obtain a capillary blood glucose
reading for a stable diabetic client.
B. Delegate assessment of new onset shortness of breath.
C. Ask the assistant to ambulate a fall-risk client who
requires one-person assistance.
D. Delegate routine oral care and repositioning every 2
hours.
E. Ask the assistant to measure and record intake/output
from a Foley drainage bag.
Answers: A, D, E.
Rationale: Delegation is appropriate for routine, stable tasks
within the assistant’s training (A, D, E). New or worsening
assessments (B) and tasks requiring clinical judgment or higher
skill (C, depending on mobility level) are not appropriate. The
PN retains accountability.
Citation: Chapter 1 — Aspects of Medical-Surgical Nursing.
, 4. (Scenario — Single best answer)
A client who speaks limited English is scheduled for an
invasive procedure. The PN learns the client’s family
member offers to translate. Which action should the PN
take?
A. Accept the family member as translator since they are
familiar with the client.
B. Use the family member only for cultural context and
arrange a professional interpreter for consent discussion.
C. Proceed with teaching using simplified English and
gestures.
D. Reschedule the procedure until a bilingual staff member
is available.
Answer: B. Use the family member only for cultural context and
arrange a professional interpreter for consent discussion.
Rationale: Professional interpreters are required for informed
consent and clinical information to ensure accuracy and
legal/ethical standards. Family may provide support but not be
sole translator for clinical decisions.
Citation: Chapter 1 — Aspects of Medical-Surgical Nursing.
5. (Standard — Single best answer)
A PN documents “patient refusing care” in the chart after a
client declined a scheduled x-ray. Which additional
documentation detail is most important?
Practical Nursing in Canada, 1st Edition
Authors:
Katherine Poser,Adrianne Dill Linton,Mary
Ann Matteson
TEST BANK.
Source: Linton and Matteson's Medical-Surgical Practical
Nursing in Canada
(Chapter used: Chapter 1 — Aspects of Medical-Surgical
Nursing)
1. (Standard — Single best answer)
A 72-year-old post-operative client is admitted after a
below-knee amputation. The PN receives the handover
, and notes the client is sleepy but arousable, RR 10/min,
SpO₂ 88% on room air, O₂ sat 95% earlier in PACU. Which
action should the PN perform first?
A. Reassess pain score and give PRN opioid.
B. Encourage deep breathing and coughing.
C. Apply supplemental oxygen and re-assess SpO₂.
D. Report change to the surgeon.
Answer: C. Apply supplemental oxygen and re-assess SpO₂.
Rationale: Hypoxemia (SpO₂ 88%) is an immediate physiologic
threat. The nurse’s first action is to restore adequate
oxygenation, then reassess and address causes. Reporting and
pain management follow stabilization.
Citation: Chapter 1 — Aspects of Medical-Surgical Nursing.
2. (Priority — First action)
During morning rounds, a client with chest pain reports
sudden palpitations and lightheadedness. Telemetry shows
new-onset ventricular tachycardia (VT) with a pulse of 42
bpm. What is the PN’s first action?
A. Prepare to administer IV amiodarone.
B. Call the rapid response team and stay with the client.
C. Take the client’s blood pressure and complete the ECG.
D. Place the client on oxygen and increase the IV fluid rate.
Answer: B. Call the rapid response team and stay with the
client.
Rationale: New symptomatic VT with bradycardia is unstable—
,immediate escalation (RRT/code) and continuous monitoring
while remaining with the client is priority. Medication and
diagnostics follow the team’s directives.
Citation: Chapter 1 — Aspects of Medical-Surgical Nursing.
3. (SATA — Select all that apply)
Which of the following actions are appropriate for safe
delegation of tasks to a nursing assistant (unregulated care
provider) for a stable medical-surgical client? (Select all
that apply.)
A. Ask the assistant to obtain a capillary blood glucose
reading for a stable diabetic client.
B. Delegate assessment of new onset shortness of breath.
C. Ask the assistant to ambulate a fall-risk client who
requires one-person assistance.
D. Delegate routine oral care and repositioning every 2
hours.
E. Ask the assistant to measure and record intake/output
from a Foley drainage bag.
Answers: A, D, E.
Rationale: Delegation is appropriate for routine, stable tasks
within the assistant’s training (A, D, E). New or worsening
assessments (B) and tasks requiring clinical judgment or higher
skill (C, depending on mobility level) are not appropriate. The
PN retains accountability.
Citation: Chapter 1 — Aspects of Medical-Surgical Nursing.
, 4. (Scenario — Single best answer)
A client who speaks limited English is scheduled for an
invasive procedure. The PN learns the client’s family
member offers to translate. Which action should the PN
take?
A. Accept the family member as translator since they are
familiar with the client.
B. Use the family member only for cultural context and
arrange a professional interpreter for consent discussion.
C. Proceed with teaching using simplified English and
gestures.
D. Reschedule the procedure until a bilingual staff member
is available.
Answer: B. Use the family member only for cultural context and
arrange a professional interpreter for consent discussion.
Rationale: Professional interpreters are required for informed
consent and clinical information to ensure accuracy and
legal/ethical standards. Family may provide support but not be
sole translator for clinical decisions.
Citation: Chapter 1 — Aspects of Medical-Surgical Nursing.
5. (Standard — Single best answer)
A PN documents “patient refusing care” in the chart after a
client declined a scheduled x-ray. Which additional
documentation detail is most important?
