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. (Standard) A 68-year-old client admitted with community-
acquired pneumonia has a sudden increase in respiratory
rate from 20 to 30 breaths/min and oxygen saturation
from 95% to 88% on 2 L/min nasal cannula over 30
minutes. Which action should the practical nurse perform
, first?
A. Call the physician for change in therapy.
B. Increase oxygen to 4 L/min and reassess.
C. Obtain arterial blood gas (ABG).
D. Reposition client to high-Fowler’s and auscultate lungs.
Answer: D. Reposition client to high-Fowler’s and auscultate
lungs.
Rationale: Immediate bedside assessment (positioning +
focused auscultation) is the fastest first action to evaluate cause
of hypoxemia and may improve ventilation; interventions for
oxygen escalation or diagnostic tests follow assessment.
Prioritize actions that address airway/oxygenation first.
2. (Priority) During change of shift report, which client should
the PN see first?
A. Postoperative appendectomy, pain 6/10, stable vitals.
B. Chronic COPD, on 3 L O₂, alert and conversing.
C. New admission with confusion, temperature 39.3°C, HR
110.
D. IV antibiotic infusion started 20 minutes ago, no
reaction noted.
Answer: C. New admission with confusion, temperature 39.3°C,
HR 110.
Rationale: Acute fever with new confusion and tachycardia
suggests sepsis or rapid deterioration—needs immediate
,assessment. Prioritization: unstable/new acute changes over
expected postoperative pain or routine IV infusion.
3. (SATA) Which tasks are appropriate to delegate to a
nursing care aide for a stable medical-surgical client?
(Select all that apply.)
A. Assist with ambulation using a gait belt.
B. Take and record a focused respiratory assessment.
C. Apply antiembolism stockings after RN assessment.
D. Reinforce teaching about new insulin administration.
E. Measure and record intake and output.
Answer: A, C, E.
Rationale: Aides may assist with ambulation (with gait belt) and
apply stockings after RN/PN assessment and instruction, and
record I&O. They should not perform focused assessments or
provide teaching that requires clinical judgement or medication
education. Delegation must match competence and
accountability.
4. (Scenario) A client with chronic heart failure (HF) shows 3-
lb weight gain in 48 hours, increasing peripheral edema,
and dyspnea on exertion. Which intervention should the
PN implement first?
A. Notify the physician to order a diuretic bolus.
B. Review daily weights and reinforce low-sodium
, teaching.
C. Assess lung sounds and oxygen saturation.
D. Restrict fluids and place on strict I&O.
Answer: C. Assess lung sounds and oxygen saturation.
Rationale: Clinical assessment identifies current
cardiopulmonary status and guides immediate interventions
(e.g., oxygen, diuretic). While notifying physician, education,
and fluid restrictions are important, the PN must first assess to
determine acuity and safety.
5. (Standard) A practical nurse notes a handwritten
medication order for warfarin without dosage. The unit RN
is unavailable. What is the most appropriate action?
A. Give the usual dose based on previous charted dose.
B. Hold the medication and document refusal.
C. Contact the prescriber for clarification before
administering.
D. Ask a senior PN to decide the dose.
Answer: C. Contact the prescriber for clarification before
administering.
Rationale: Safety principle: never administer meds with
incomplete orders. Clarify with prescriber to avoid dosing
errors. Holding without clarification or using previous dose
without an order is unsafe. Delegating decision to another
nurse without prescriber clarification is also inappropriate.
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. (Standard) A 68-year-old client admitted with community-
acquired pneumonia has a sudden increase in respiratory
rate from 20 to 30 breaths/min and oxygen saturation
from 95% to 88% on 2 L/min nasal cannula over 30
minutes. Which action should the practical nurse perform
, first?
A. Call the physician for change in therapy.
B. Increase oxygen to 4 L/min and reassess.
C. Obtain arterial blood gas (ABG).
D. Reposition client to high-Fowler’s and auscultate lungs.
Answer: D. Reposition client to high-Fowler’s and auscultate
lungs.
Rationale: Immediate bedside assessment (positioning +
focused auscultation) is the fastest first action to evaluate cause
of hypoxemia and may improve ventilation; interventions for
oxygen escalation or diagnostic tests follow assessment.
Prioritize actions that address airway/oxygenation first.
2. (Priority) During change of shift report, which client should
the PN see first?
A. Postoperative appendectomy, pain 6/10, stable vitals.
B. Chronic COPD, on 3 L O₂, alert and conversing.
C. New admission with confusion, temperature 39.3°C, HR
110.
D. IV antibiotic infusion started 20 minutes ago, no
reaction noted.
Answer: C. New admission with confusion, temperature 39.3°C,
HR 110.
Rationale: Acute fever with new confusion and tachycardia
suggests sepsis or rapid deterioration—needs immediate
,assessment. Prioritization: unstable/new acute changes over
expected postoperative pain or routine IV infusion.
3. (SATA) Which tasks are appropriate to delegate to a
nursing care aide for a stable medical-surgical client?
(Select all that apply.)
A. Assist with ambulation using a gait belt.
B. Take and record a focused respiratory assessment.
C. Apply antiembolism stockings after RN assessment.
D. Reinforce teaching about new insulin administration.
E. Measure and record intake and output.
Answer: A, C, E.
Rationale: Aides may assist with ambulation (with gait belt) and
apply stockings after RN/PN assessment and instruction, and
record I&O. They should not perform focused assessments or
provide teaching that requires clinical judgement or medication
education. Delegation must match competence and
accountability.
4. (Scenario) A client with chronic heart failure (HF) shows 3-
lb weight gain in 48 hours, increasing peripheral edema,
and dyspnea on exertion. Which intervention should the
PN implement first?
A. Notify the physician to order a diuretic bolus.
B. Review daily weights and reinforce low-sodium
, teaching.
C. Assess lung sounds and oxygen saturation.
D. Restrict fluids and place on strict I&O.
Answer: C. Assess lung sounds and oxygen saturation.
Rationale: Clinical assessment identifies current
cardiopulmonary status and guides immediate interventions
(e.g., oxygen, diuretic). While notifying physician, education,
and fluid restrictions are important, the PN must first assess to
determine acuity and safety.
5. (Standard) A practical nurse notes a handwritten
medication order for warfarin without dosage. The unit RN
is unavailable. What is the most appropriate action?
A. Give the usual dose based on previous charted dose.
B. Hold the medication and document refusal.
C. Contact the prescriber for clarification before
administering.
D. Ask a senior PN to decide the dose.
Answer: C. Contact the prescriber for clarification before
administering.
Rationale: Safety principle: never administer meds with
incomplete orders. Clarify with prescriber to avoid dosing
errors. Holding without clarification or using previous dose
without an order is unsafe. Delegating decision to another
nurse without prescriber clarification is also inappropriate.
