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 68-year-old postoperative client is receiving opioid
analgesia. The client is somnolent but arousable,
, respiratory rate 10/min, and oxygen saturation 92% on
room air. Which nursing action is the priority?
A. Administer naloxone per standing order.
B. Reposition the client and encourage deep breathing.
C. Reduce the opioid dose and notify the prescriber.
D. Stimulate the client and reassess respiratory rate and
oxygen saturation.
Answer: D
Rationale: Immediate bedside assessment and stimulation to
confirm responsiveness and reassess vital signs is the priority
before giving reversal agents or changing medication orders.
This follows the nursing process: assess → intervene
(stimulation/oxygen) → escalate if no improvement.
Citation: Linton & Matteson — Chapter 1: Aspects of Medical-
Surgical Nursing.
2. (Priority)
A PN is assigned three clients. Which assignment should
the PN see first?
A. A client 2 hours post-op with moderate incisional pain
controlled by PRN opioids.
B. A client with diabetes and blood glucose 3.4 mmol/L
(low) who is pale and diaphoretic.
C. A client awaiting discharge teaching regarding home
wound care.
, D. A stable client requesting social work referral for long-
term care placement.
Answer: B
Rationale: Hypoglycemia (3.4 mmol/L) with sympathetic signs is
an immediately unstable condition that can progress to
confusion, seizures, or loss of consciousness and requires
immediate treatment. Priority follows
airway/breathing/circulation and acute destabilization.
Citation: Linton & Matteson — Chapter 1.
3. (SATA — select all that apply)
Which of the following tasks are within the PN/LPN scope
and may be delegated to the PN by an RN for a stable
medical-surgical client? (Select all that apply.)
A. Administering oral pain medication with documented
PRN parameters.
B. Initiating a blood transfusion and monitoring for
reaction.
C. Reinforcing teaching about a prescribed dressing change
previously taught by the RN.
D. Performing a focused respiratory assessment and
reporting abnormalities.
E. Developing the initial nursing care plan for a newly
admitted unstable client.
Answer: A, C, D
Rationale: PNs can administer medications per scope and
, facility policy (A), reinforce teaching within their competency
when initial teaching provided by RN (C), and perform focused
assessments and report findings (D). Initiating transfusions (B)
and developing initial plans for unstable clients (E) are RN
responsibilities or require higher level assessment/judgment.
Citation: Linton & Matteson — Chapter 1.
4. (Scenario — single best answer)
A client with chronic heart failure reports sudden weight
gain of 3 kg in 48 hours and increased shortness of breath
when lying flat. Which action should the PN perform first?
A. Instruct the client to restrict fluid intake and salt.
B. Place the client in high-Fowler’s position and assess lung
sounds.
C. Give the prescribed diuretic and document
intake/output.
D. Notify the primary care provider of the change in status.
Answer: B
Rationale: Sudden weight gain and orthopnea suggest acute
fluid overload; immediate assessment (positioning to improve
breathing and lung auscultation) is the priority to determine
degree of respiratory compromise before medication or
notification.
Citation: Linton & Matteson — Chapter 1.
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 68-year-old postoperative client is receiving opioid
analgesia. The client is somnolent but arousable,
, respiratory rate 10/min, and oxygen saturation 92% on
room air. Which nursing action is the priority?
A. Administer naloxone per standing order.
B. Reposition the client and encourage deep breathing.
C. Reduce the opioid dose and notify the prescriber.
D. Stimulate the client and reassess respiratory rate and
oxygen saturation.
Answer: D
Rationale: Immediate bedside assessment and stimulation to
confirm responsiveness and reassess vital signs is the priority
before giving reversal agents or changing medication orders.
This follows the nursing process: assess → intervene
(stimulation/oxygen) → escalate if no improvement.
Citation: Linton & Matteson — Chapter 1: Aspects of Medical-
Surgical Nursing.
2. (Priority)
A PN is assigned three clients. Which assignment should
the PN see first?
A. A client 2 hours post-op with moderate incisional pain
controlled by PRN opioids.
B. A client with diabetes and blood glucose 3.4 mmol/L
(low) who is pale and diaphoretic.
C. A client awaiting discharge teaching regarding home
wound care.
, D. A stable client requesting social work referral for long-
term care placement.
Answer: B
Rationale: Hypoglycemia (3.4 mmol/L) with sympathetic signs is
an immediately unstable condition that can progress to
confusion, seizures, or loss of consciousness and requires
immediate treatment. Priority follows
airway/breathing/circulation and acute destabilization.
Citation: Linton & Matteson — Chapter 1.
3. (SATA — select all that apply)
Which of the following tasks are within the PN/LPN scope
and may be delegated to the PN by an RN for a stable
medical-surgical client? (Select all that apply.)
A. Administering oral pain medication with documented
PRN parameters.
B. Initiating a blood transfusion and monitoring for
reaction.
C. Reinforcing teaching about a prescribed dressing change
previously taught by the RN.
D. Performing a focused respiratory assessment and
reporting abnormalities.
E. Developing the initial nursing care plan for a newly
admitted unstable client.
Answer: A, C, D
Rationale: PNs can administer medications per scope and
, facility policy (A), reinforce teaching within their competency
when initial teaching provided by RN (C), and perform focused
assessments and report findings (D). Initiating transfusions (B)
and developing initial plans for unstable clients (E) are RN
responsibilities or require higher level assessment/judgment.
Citation: Linton & Matteson — Chapter 1.
4. (Scenario — single best answer)
A client with chronic heart failure reports sudden weight
gain of 3 kg in 48 hours and increased shortness of breath
when lying flat. Which action should the PN perform first?
A. Instruct the client to restrict fluid intake and salt.
B. Place the client in high-Fowler’s position and assess lung
sounds.
C. Give the prescribed diuretic and document
intake/output.
D. Notify the primary care provider of the change in status.
Answer: B
Rationale: Sudden weight gain and orthopnea suggest acute
fluid overload; immediate assessment (positioning to improve
breathing and lung auscultation) is the priority to determine
degree of respiratory compromise before medication or
notification.
Citation: Linton & Matteson — Chapter 1.
