Linton and Matteson's Medical-Surgical
Practical Nursing in Canada, 1st Edition
Authors:
Katherine Poser,Adrianne Dill Linton,Mary
Ann Matteson
TEST BANK.
1. A 72-year-old postoperative client is confused and
agitated. Which nursing action takes highest priority
initially?
A. Ask the family for information about the client’s
baseline cognition.
B. Review the client’s medication administration
record (MAR) for recent opioids or sedatives.
C. Perform a focused neurological assessment and
, measure oxygen saturation.
D. Reassure the client and offer a pain rating scale.
Correct answer: C
Rationale: Acute confusion postoperatively may indicate
hypoxia, stroke, or other acute problems — assessing
neuro status and SpO₂ identifies immediate threats (ABCs)
before other steps.
Citation: Chapter 1 — Aspects of Medical–Surgical
Nursing.
2. Which element best represents the nursing process as
used in medical-surgical practice?
A. Performing tasks delegated by the RN.
B. Using standardized templates only for
documentation.
C. Assessment, diagnosis, planning, implementation,
evaluation.
D. Relying primarily on physician orders to guide care.
Correct answer: C
Rationale: The nursing process is a cyclical framework
(ADPIE) that guides individualized care; it is central to PN
practice in medical-surgical settings.
,Citation: Chapter 1 — Aspects of Medical–Surgical
Nursing.
3. Select all that apply. Which responsibilities are within
the typical scope of practice for a Practical Nurse (PN)
in medical-surgical settings? (Select all that apply.)
A. Concluding a new nursing diagnosis and
prescribing therapy.
B. Performing focused nursing assessments and
reporting findings.
C. Administering medications per facility policy and
prescriber orders.
D. Delegating nursing judgment tasks to unregulated
assistive personnel (UAP).
E. Implementing nursing interventions within
established care plans.
Correct answers: B, C, E
Rationale: PNs perform assessments, give medications per
orders, and implement interventions. Diagnosing and
prescribing are out of PN scope; delegation of judgment
tasks to UAP is inappropriate.
Citation: Chapter 1 — Aspects of Medical–Surgical
Nursing.
, 4. A nurse documents "patient tolerated procedure well"
after wound dressing change. Which improvement
makes the note more clinically useful?
A. "Patient tolerated dressing change adequately."
B. "Patient tolerated dressing change; no signs of
distress; tolerated procedure with minimal grimacing."
C. "Patient did fine."
D. "Patient tolerated dressing change; will reassess
later."
Correct answer: B
Rationale: Effective documentation is specific, objective,
and includes observable data (e.g., signs of distress) rather
than vague statements.
Citation: Chapter 1 — Aspects of Medical–Surgical
Nursing.
5. A client verbalizes a wish to refuse a recommended
procedure. Which nursing action is most appropriate?
A. Explain that refusal may result in immediate
discharge.
B. Notify the physician and document the refusal after
trying to persuade the client.
Practical Nursing in Canada, 1st Edition
Authors:
Katherine Poser,Adrianne Dill Linton,Mary
Ann Matteson
TEST BANK.
1. A 72-year-old postoperative client is confused and
agitated. Which nursing action takes highest priority
initially?
A. Ask the family for information about the client’s
baseline cognition.
B. Review the client’s medication administration
record (MAR) for recent opioids or sedatives.
C. Perform a focused neurological assessment and
, measure oxygen saturation.
D. Reassure the client and offer a pain rating scale.
Correct answer: C
Rationale: Acute confusion postoperatively may indicate
hypoxia, stroke, or other acute problems — assessing
neuro status and SpO₂ identifies immediate threats (ABCs)
before other steps.
Citation: Chapter 1 — Aspects of Medical–Surgical
Nursing.
2. Which element best represents the nursing process as
used in medical-surgical practice?
A. Performing tasks delegated by the RN.
B. Using standardized templates only for
documentation.
C. Assessment, diagnosis, planning, implementation,
evaluation.
D. Relying primarily on physician orders to guide care.
Correct answer: C
Rationale: The nursing process is a cyclical framework
(ADPIE) that guides individualized care; it is central to PN
practice in medical-surgical settings.
,Citation: Chapter 1 — Aspects of Medical–Surgical
Nursing.
3. Select all that apply. Which responsibilities are within
the typical scope of practice for a Practical Nurse (PN)
in medical-surgical settings? (Select all that apply.)
A. Concluding a new nursing diagnosis and
prescribing therapy.
B. Performing focused nursing assessments and
reporting findings.
C. Administering medications per facility policy and
prescriber orders.
D. Delegating nursing judgment tasks to unregulated
assistive personnel (UAP).
E. Implementing nursing interventions within
established care plans.
Correct answers: B, C, E
Rationale: PNs perform assessments, give medications per
orders, and implement interventions. Diagnosing and
prescribing are out of PN scope; delegation of judgment
tasks to UAP is inappropriate.
Citation: Chapter 1 — Aspects of Medical–Surgical
Nursing.
, 4. A nurse documents "patient tolerated procedure well"
after wound dressing change. Which improvement
makes the note more clinically useful?
A. "Patient tolerated dressing change adequately."
B. "Patient tolerated dressing change; no signs of
distress; tolerated procedure with minimal grimacing."
C. "Patient did fine."
D. "Patient tolerated dressing change; will reassess
later."
Correct answer: B
Rationale: Effective documentation is specific, objective,
and includes observable data (e.g., signs of distress) rather
than vague statements.
Citation: Chapter 1 — Aspects of Medical–Surgical
Nursing.
5. A client verbalizes a wish to refuse a recommended
procedure. Which nursing action is most appropriate?
A. Explain that refusal may result in immediate
discharge.
B. Notify the physician and document the refusal after
trying to persuade the client.
