Medical-Surgical Nursing
8th Edition
Author(s)Adrianne Dill Linton;
Mary Ann Matteson
Print ISBN: 9780323826716
TEST BANK
Below is an original, mixed-difficulty 20-item revision bank
aligned to Chapter 1: Foundations for Medical-Surgical
Nursing. Because no distribution was specified, I used a
balanced mix of item types and kept every scenario within the
chapter’s foundation-level concepts: clinical judgment, nursing
,process, evidence-based care, patient-centered care, safety,
documentation, and collaboration.
1. MCQ
Clinical Scenario:
A postoperative patient received IV morphine 30 minutes ago
for severe pain. The patient is now difficult to arouse,
respirations are 10/min, and oxygen saturation is 90% on room
air.
Question Stem:
What is the nurse’s first action?
Answer Options:
A. Document that the patient is sleeping after pain medication
B. Wake the patient, assess respirations, and apply oxygen per
protocol
C. Administer the next scheduled dose of analgesic to prevent
splinting
D. Place the patient in the supine position and leave them
undisturbed
Correct Answer:
B
Detailed Rationale:
The patient shows cues of possible opioid-induced respiratory
,depression. The nurse must recognize the deterioration
immediately, assess airway and breathing, stimulate the
patient, and support oxygenation per protocol. This is a safety-
first response and reflects early intervention to prevent
hypoventilation, hypoxemia, and respiratory arrest.
Incorrect Option Analysis:
A: Incorrect. Sleeping does not explain difficult arousal
with low respirations. Misconception: assuming sedation is
expected. Risk: delayed rescue.
C: Incorrect. Additional opioid could worsen respiratory
depression. Misconception: treating pain without
reassessing safety. Risk: arrest.
D: Incorrect. Supine positioning may further impair
ventilation. Misconception: “resting” is safe. Risk:
worsening hypoxia.
Nursing Process Linkage:
Assessment
NCJMM Competencies:
Recognize Cues; Take Action
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
, NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify and respond to opioid-related respiratory compromise
using immediate assessment and safety priorities.
2. MCQ
Clinical Scenario:
A nurse is revising a postoperative pulmonary hygiene protocol
to reduce atelectasis and pneumonia.
Question Stem:
Which intervention has the strongest evidence for preventing
postoperative pulmonary complications?
Answer Options:
A. Routine suctioning every 4 hours
B. Incentive spirometry and early ambulation
C. Restricting oral fluids until bowel sounds return
D. Keeping the patient flat in bed to reduce fatigue
Correct Answer:
B
Detailed Rationale:
Early ambulation and incentive spirometry improve lung
expansion, mobilize secretions, and reduce atelectasis risk. This
8th Edition
Author(s)Adrianne Dill Linton;
Mary Ann Matteson
Print ISBN: 9780323826716
TEST BANK
Below is an original, mixed-difficulty 20-item revision bank
aligned to Chapter 1: Foundations for Medical-Surgical
Nursing. Because no distribution was specified, I used a
balanced mix of item types and kept every scenario within the
chapter’s foundation-level concepts: clinical judgment, nursing
,process, evidence-based care, patient-centered care, safety,
documentation, and collaboration.
1. MCQ
Clinical Scenario:
A postoperative patient received IV morphine 30 minutes ago
for severe pain. The patient is now difficult to arouse,
respirations are 10/min, and oxygen saturation is 90% on room
air.
Question Stem:
What is the nurse’s first action?
Answer Options:
A. Document that the patient is sleeping after pain medication
B. Wake the patient, assess respirations, and apply oxygen per
protocol
C. Administer the next scheduled dose of analgesic to prevent
splinting
D. Place the patient in the supine position and leave them
undisturbed
Correct Answer:
B
Detailed Rationale:
The patient shows cues of possible opioid-induced respiratory
,depression. The nurse must recognize the deterioration
immediately, assess airway and breathing, stimulate the
patient, and support oxygenation per protocol. This is a safety-
first response and reflects early intervention to prevent
hypoventilation, hypoxemia, and respiratory arrest.
Incorrect Option Analysis:
A: Incorrect. Sleeping does not explain difficult arousal
with low respirations. Misconception: assuming sedation is
expected. Risk: delayed rescue.
C: Incorrect. Additional opioid could worsen respiratory
depression. Misconception: treating pain without
reassessing safety. Risk: arrest.
D: Incorrect. Supine positioning may further impair
ventilation. Misconception: “resting” is safe. Risk:
worsening hypoxia.
Nursing Process Linkage:
Assessment
NCJMM Competencies:
Recognize Cues; Take Action
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
, NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify and respond to opioid-related respiratory compromise
using immediate assessment and safety priorities.
2. MCQ
Clinical Scenario:
A nurse is revising a postoperative pulmonary hygiene protocol
to reduce atelectasis and pneumonia.
Question Stem:
Which intervention has the strongest evidence for preventing
postoperative pulmonary complications?
Answer Options:
A. Routine suctioning every 4 hours
B. Incentive spirometry and early ambulation
C. Restricting oral fluids until bowel sounds return
D. Keeping the patient flat in bed to reduce fatigue
Correct Answer:
B
Detailed Rationale:
Early ambulation and incentive spirometry improve lung
expansion, mobilize secretions, and reduce atelectasis risk. This
