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 postoperative patient with COPD is receiving
oxygen at 2 L/min via nasal cannula. During your hourly
, assessment you note the patient’s respiratory rate has
increased from 18 to 30/min, accessory muscle use, and a
drop in SpO₂ from 95% to 88%. Which nursing action is the
most appropriate immediate response within PN scope?
A. Increase oxygen to 4 L/min and continue hourly checks.
B. Place the patient in high-Fowler’s position, administer
prescribed bronchodilator via nebulizer if available, and
notify the registered nurse/physician.
C. Withhold oxygen and encourage pursed-lip breathing.
D. Document findings and recheck in 30 minutes.
Answer: B
Rationale: Acute deterioration signs (↑RR, accessory muscle
use, SpO₂ 88%) require immediate interventions to improve
ventilation (upright position) and prompt escalation.
Administering prescribed bronchodilator (if within PN
responsibilities and available) and notifying RN/physician
reflects prioritization and delegation/communication principles
in the chapter.
2. (Priority — first action)
A client on the med-surg unit complains of chest pressure
and diaphoresis. Vital signs: BP 140/86, HR 110 irregular,
RR 24, SpO₂ 96% on room air. What is the nurse’s priority
first action?
A. Obtain a 12-lead ECG.
B. Give PRN analgesic for chest pain.
, C. Place the client on continuous cardiac monitoring and
call the RN/physician immediately.
D. Document the event and continue monitoring.
Answer: C
Rationale: Chest pressure with tachycardia and diaphoresis
suggests possible cardiac ischemia/arrhythmia. Immediate
monitoring and urgent notification ensure rapid assessment
and escalation — prioritized in the chapter’s approach to early
recognition of deterioration.
3. (Standard — single best answer)
A PN is assigned to care for four clients. Which task should
the PN consider delegating to an experienced unregulated
health worker (UHW)?
A. Teach a client about new anticoagulant dosing and side
effects.
B. Measure and record routine vital signs on a stable
postoperative client.
C. Evaluate the effectiveness of analgesic therapy and
adjust plan as needed.
D. Perform tracheostomy suctioning for a client with a
fresh tracheostomy.
Answer: B
Rationale: Routine vital signs on a stable client are within
typical delegation to UHW; teaching, clinical evaluation, and
, invasive procedures require licensed nurse skills as outlined in
scope/delegation content of the chapter.
4. (SATA — select all that apply)
Which of the following actions support accurate and legally
sound documentation? (Select all that apply.)
A. Document subjective complaints exactly as the client
stated, in quotation marks.
B. Use vague phrases such as “patient stable” when
recording complex findings.
C. Record objective data, time-stamped, and sign with
designation.
D. Correct an entry by striking through the mistake with a
single line, initialing and dating the correction.
E. Add retrospective entries without indicating the actual
time the event occurred.
Answer: A, C, D
Rationale: Accurate documentation requires verbatim quotes
for subjective data, objective data with time/signature, and
proper correction procedure. Vague phrasing and undisclosed
retrospective entries violate documentation/legal guidelines
discussed in the chapter.
5. (Standard — single best answer)
A client refuses morning lab work after learning it requires
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 postoperative patient with COPD is receiving
oxygen at 2 L/min via nasal cannula. During your hourly
, assessment you note the patient’s respiratory rate has
increased from 18 to 30/min, accessory muscle use, and a
drop in SpO₂ from 95% to 88%. Which nursing action is the
most appropriate immediate response within PN scope?
A. Increase oxygen to 4 L/min and continue hourly checks.
B. Place the patient in high-Fowler’s position, administer
prescribed bronchodilator via nebulizer if available, and
notify the registered nurse/physician.
C. Withhold oxygen and encourage pursed-lip breathing.
D. Document findings and recheck in 30 minutes.
Answer: B
Rationale: Acute deterioration signs (↑RR, accessory muscle
use, SpO₂ 88%) require immediate interventions to improve
ventilation (upright position) and prompt escalation.
Administering prescribed bronchodilator (if within PN
responsibilities and available) and notifying RN/physician
reflects prioritization and delegation/communication principles
in the chapter.
2. (Priority — first action)
A client on the med-surg unit complains of chest pressure
and diaphoresis. Vital signs: BP 140/86, HR 110 irregular,
RR 24, SpO₂ 96% on room air. What is the nurse’s priority
first action?
A. Obtain a 12-lead ECG.
B. Give PRN analgesic for chest pain.
, C. Place the client on continuous cardiac monitoring and
call the RN/physician immediately.
D. Document the event and continue monitoring.
Answer: C
Rationale: Chest pressure with tachycardia and diaphoresis
suggests possible cardiac ischemia/arrhythmia. Immediate
monitoring and urgent notification ensure rapid assessment
and escalation — prioritized in the chapter’s approach to early
recognition of deterioration.
3. (Standard — single best answer)
A PN is assigned to care for four clients. Which task should
the PN consider delegating to an experienced unregulated
health worker (UHW)?
A. Teach a client about new anticoagulant dosing and side
effects.
B. Measure and record routine vital signs on a stable
postoperative client.
C. Evaluate the effectiveness of analgesic therapy and
adjust plan as needed.
D. Perform tracheostomy suctioning for a client with a
fresh tracheostomy.
Answer: B
Rationale: Routine vital signs on a stable client are within
typical delegation to UHW; teaching, clinical evaluation, and
, invasive procedures require licensed nurse skills as outlined in
scope/delegation content of the chapter.
4. (SATA — select all that apply)
Which of the following actions support accurate and legally
sound documentation? (Select all that apply.)
A. Document subjective complaints exactly as the client
stated, in quotation marks.
B. Use vague phrases such as “patient stable” when
recording complex findings.
C. Record objective data, time-stamped, and sign with
designation.
D. Correct an entry by striking through the mistake with a
single line, initialing and dating the correction.
E. Add retrospective entries without indicating the actual
time the event occurred.
Answer: A, C, D
Rationale: Accurate documentation requires verbatim quotes
for subjective data, objective data with time/signature, and
proper correction procedure. Vague phrasing and undisclosed
retrospective entries violate documentation/legal guidelines
discussed in the chapter.
5. (Standard — single best answer)
A client refuses morning lab work after learning it requires
