Linton and Matteson's Medical-Surgical
Practical Nursing in Canada, 1st Edition
Authors:
Katherine Poser,Adrianne Dill Linton,Mary
Ann Matteson
TEST BANK.
Medical–Surgical Practical Nursing — Test Bank
Chapter 1: Aspects of Medical-Surgical Nursing
1. Type: Standard (Single-best-answer)
A 68-year-old client admitted for exacerbation of chronic
obstructive pulmonary disease (COPD) is receiving oxygen
by nasal cannula at 2 L/min. The client’s respiratory rate
has increased from 20 to 30 breaths/min over the past
, hour, pulse oximetry decreased from 95% to 89%, and the
client appears more anxious and using accessory muscles.
Which action should the practical nurse take first?
A. Increase oxygen to 4 L/min via nasal cannula.
B. Encourage the client to use pursed-lip breathing and sit
up on the side of the bed.
C. Notify the registered nurse and prepare for possible
transfer to higher level of care.
D. Obtain an arterial blood gas (ABG) sample.
Answer: B. Encourage the client to use pursed-lip breathing and
sit up on the side of the bed.
Rationale: Immediate nursing interventions that improve
ventilation and reduce work of breathing (positioning,
breathing techniques) are priority before escalating oxygen or
invasive diagnostics. This is within PN scope and stabilizes the
patient while initiating further assessment.
Citation: Linton & Matteson, Medical–Surgical Practical Nursing
in Canada, 1st ed. — Chapter: Aspects of Medical–Surgical
Nursing
2. Type: Priority (First-action)
A postoperative client 2 hours after abdominal surgery has
a blood pressure of 88/54 mm Hg (baseline 120/78), heart
rate 118 bpm, urine output 10 mL in past hour, and cool,
clammy skin. What is the PN’s first action?
A. Increase the IV infusion rate of the prescribed crystalloid
, and call the RN.
B. Raise the head of the bed to 45 degrees and re-assess
vital signs.
C. Apply oxygen at 2 L/min via nasal cannula and
encourage coughing.
D. Obtain a urine catheter to accurately measure output.
Answer: A. Increase the IV infusion rate of the prescribed
crystalloid and call the RN.
Rationale: Signs indicate hypovolemia/shock — immediate fluid
resuscitation (within PN scope if per protocol/prescription) and
notifying RN are priorities to restore perfusion. Positioning
upright would worsen hypotension.
Citation: Linton & Matteson, Medical–Surgical Practical Nursing
in Canada, 1st ed. — Chapter: Aspects of Medical–Surgical
Nursing
3. Type: SATA (Select all that apply)
Which activities are appropriate to delegate to an
experienced unlicensed assistive personnel (UAP) for a
stable medical–surgical client?
A. Assist with ambulation using a gait belt.
B. Perform medication administration of oral analgesic.
C. Measure and record 24-hour intake and output.
D. Reinforce teaching about a new anticoagulant.
E. Provide routine perineal care.
, Answer: A, C, E.
Rationale: Delegation depends on stability, complexity, and
required judgment. UAP can assist ambulation with a gait belt,
record I&O, and provide hygiene. Medication administration
and patient teaching requiring clinical judgment and
assessment are RN/PN responsibilities.
Citation: Linton & Matteson, Medical–Surgical Practical Nursing
in Canada, 1st ed. — Chapter: Aspects of Medical–Surgical
Nursing
4. Type: Scenario (Clinical judgment)
A client with type 2 diabetes is admitted with a foot ulcer.
The PN observes a foul-smelling drainage, surrounding
erythema extending toward the ankle, and the client
reports increasing pain despite prescribed analgesics. Vital
signs: T 38.3°C, HR 106, BP 130/78. What is the most
important nursing priority?
A. Apply sterile dressing and continue scheduled dressing
changes.
B. Obtain wound culture and notify the RN/physician of
suspected spreading infection.
C. Administer PRN analgesic and reassess pain in 30
minutes.
D. Teach the client about glycemic control and foot care.
Answer: B. Obtain wound culture and notify the RN/physician
of suspected spreading infection.
Practical Nursing in Canada, 1st Edition
Authors:
Katherine Poser,Adrianne Dill Linton,Mary
Ann Matteson
TEST BANK.
Medical–Surgical Practical Nursing — Test Bank
Chapter 1: Aspects of Medical-Surgical Nursing
1. Type: Standard (Single-best-answer)
A 68-year-old client admitted for exacerbation of chronic
obstructive pulmonary disease (COPD) is receiving oxygen
by nasal cannula at 2 L/min. The client’s respiratory rate
has increased from 20 to 30 breaths/min over the past
, hour, pulse oximetry decreased from 95% to 89%, and the
client appears more anxious and using accessory muscles.
Which action should the practical nurse take first?
A. Increase oxygen to 4 L/min via nasal cannula.
B. Encourage the client to use pursed-lip breathing and sit
up on the side of the bed.
C. Notify the registered nurse and prepare for possible
transfer to higher level of care.
D. Obtain an arterial blood gas (ABG) sample.
Answer: B. Encourage the client to use pursed-lip breathing and
sit up on the side of the bed.
Rationale: Immediate nursing interventions that improve
ventilation and reduce work of breathing (positioning,
breathing techniques) are priority before escalating oxygen or
invasive diagnostics. This is within PN scope and stabilizes the
patient while initiating further assessment.
Citation: Linton & Matteson, Medical–Surgical Practical Nursing
in Canada, 1st ed. — Chapter: Aspects of Medical–Surgical
Nursing
2. Type: Priority (First-action)
A postoperative client 2 hours after abdominal surgery has
a blood pressure of 88/54 mm Hg (baseline 120/78), heart
rate 118 bpm, urine output 10 mL in past hour, and cool,
clammy skin. What is the PN’s first action?
A. Increase the IV infusion rate of the prescribed crystalloid
, and call the RN.
B. Raise the head of the bed to 45 degrees and re-assess
vital signs.
C. Apply oxygen at 2 L/min via nasal cannula and
encourage coughing.
D. Obtain a urine catheter to accurately measure output.
Answer: A. Increase the IV infusion rate of the prescribed
crystalloid and call the RN.
Rationale: Signs indicate hypovolemia/shock — immediate fluid
resuscitation (within PN scope if per protocol/prescription) and
notifying RN are priorities to restore perfusion. Positioning
upright would worsen hypotension.
Citation: Linton & Matteson, Medical–Surgical Practical Nursing
in Canada, 1st ed. — Chapter: Aspects of Medical–Surgical
Nursing
3. Type: SATA (Select all that apply)
Which activities are appropriate to delegate to an
experienced unlicensed assistive personnel (UAP) for a
stable medical–surgical client?
A. Assist with ambulation using a gait belt.
B. Perform medication administration of oral analgesic.
C. Measure and record 24-hour intake and output.
D. Reinforce teaching about a new anticoagulant.
E. Provide routine perineal care.
, Answer: A, C, E.
Rationale: Delegation depends on stability, complexity, and
required judgment. UAP can assist ambulation with a gait belt,
record I&O, and provide hygiene. Medication administration
and patient teaching requiring clinical judgment and
assessment are RN/PN responsibilities.
Citation: Linton & Matteson, Medical–Surgical Practical Nursing
in Canada, 1st ed. — Chapter: Aspects of Medical–Surgical
Nursing
4. Type: Scenario (Clinical judgment)
A client with type 2 diabetes is admitted with a foot ulcer.
The PN observes a foul-smelling drainage, surrounding
erythema extending toward the ankle, and the client
reports increasing pain despite prescribed analgesics. Vital
signs: T 38.3°C, HR 106, BP 130/78. What is the most
important nursing priority?
A. Apply sterile dressing and continue scheduled dressing
changes.
B. Obtain wound culture and notify the RN/physician of
suspected spreading infection.
C. Administer PRN analgesic and reassess pain in 30
minutes.
D. Teach the client about glycemic control and foot care.
Answer: B. Obtain wound culture and notify the RN/physician
of suspected spreading infection.
