TEST BANK FOR Medical-Surgical Nursing: Concepts for
Clinical Judgment and Collaborative Care 11th edition by
Donna D. Ignatavicius ISBN: 978-0323878265 NEW
COMPLETE GUIDE WITH RATIONALES 100% VERIFIED A+
GRADE ASSURED!!!!NEW LATEST UPDATE
1 (Topic: Advanced Hematology / QSEN Safety)
A nurse is preparing to administer an intravenous infusion of heparin to a patient with a
massive deep vein thrombosis (DVT). The patient's baseline activated partial
thromboplastin time (aPTT) is 30 seconds. Which action by the nurse best reflects the
QSEN competency of Evidence-Based Practice and Safety?
, A) Adjusting the infusion rate based on the patient's subjective report of leg pain
reduction.
B) Setting the infusion pump to deliver the heparin dose without a secondary nurse
verification.
C) Utilizing a standardized, weight-based heparin protocol to titrate the dose based on
serial aPTT values.
D) Administering the heparin via a gravity infusion set to ensure rapid delivery.
Correct Answer: C
Rationale:
Why C is correct: Standardized, weight-based heparin protocols are evidence-based
tools proven to safely achieve therapeutic anticoagulation ranges quickly while
minimizing bleeding risks. Serial aPTT tracking ensures precise titration.
Question 2 (Topic: Endocrine / Prioritization)
A patient with a history of primary hyperparathyroidism is admitted to the medical unit.
The nurse reviews the morning laboratory results and notes a serum calcium level of
14.2 mg/dL. Which collaborative intervention should the nurse prioritize first?
A) Initiating an intravenous infusion of 0.9% Normal Saline at 200 mL/hr.
B) Administering oral calcium carbonate supplements with meals.
C) Preparing the patient for an immediate diagnostic parathyroid scan.
D) Encouraging strict bed rest to prevent pathological fractures.
Correct Answer: A
Rationale:
Why A is correct: A serum calcium level of 14.2 mg/dL indicates severe hypercalcemia
(normal: 9.0–10.5 mg/dL), a medical emergency. The priority treatment is aggressive
fluid volume repletion with isotonic saline to promote renal calcium excretion and
prevent acute kidney injury.
Question 3 (Topic: Gastrointestinal / Hepatic Care)
A nurse is evaluating a patient with advanced cirrhosis who is receiving lactulose for
hepatic encephalopathy. Which finding indicates that the medication is achieving its
therapeutic goal?
, A) The patient has four soft, formed bowel movements per day.
B) The patient demonstrates increased orientation and decreased asterixis.
C) The patient's serum alanine aminotransferase (ALT) level returns to normal.
D) The patient's abdominal girth decreases by 2 centimeters.
Correct Answer: B
Rationale:
Why B is correct: Lactulose works by trapping ammonia in the gut and expelling it
through the stool. The primary therapeutic goal is the resolution of hepatic
encephalopathy, indicated by improved neurological status (orientation) and a decrease
in asterixis (liver flap).
Why A is incorrect: While lactulose causes loose stools, having four formed stools is a
secondary mechanical side effect, not the primary therapeutic metabolic metric.
Why C is incorrect: Lactulose treats the complication of liver failure (ammonia
buildup); it does not cure the underlying liver disease or lower liver enzymes like ALT.
Why D is incorrect: Reduction in abdominal girth relates to the management of ascites
(via diuretics/paracentesis), not lactulose therapy.
Hint: Focus on the specific organ system targeted by ammonia toxicity. The therapeutic
effect will always present as a change in that system.
Question 4 (Topic: Neurological Clinical Judgment)
A patient who sustained a traumatic brain injury (TBI) is being monitored in the
neurological intensive care unit. The nurse notices the patient's blood pressure has
shifted from 122/80 mmHg to 168/54 mmHg, the pulse has dropped from 78 to 48
beats/minute, and respirations are irregular. How should the nurse interpret these
findings?
A) The patient is experiencing severe hypovolemic shock.
B) The patient's condition is improving, and sedation can be safely reduced.
C) The patient is exhibiting Cushing's Triad, indicating imminent brain herniation.
D) The patient has developed autonomic dysreflexia from a spinal injury.
Correct Answer: C
Rationale:
Why C is correct: Widening pulse pressure (systolic hypertension), bradycardia, and
irregular respirations comprise Cushing's Triad. This is a late sign of drastically
increased intracranial pressure (ICP) and signals imminent brainstem herniation,
requiring immediate intervention.
Why A is incorrect: Hypovolemic shock presents with hypotension and tachycardia,
the exact opposite of these findings.
, Why B is incorrect: This is a neurological emergency pointing to a life-threatening
decline, not an improvement.
Why D is incorrect: Autonomic dysreflexia features severe hypertension and
bradycardia, but it typically occurs in patients with spinal cord injuries at or above T6,
and it does not characteristically cause irregular, bradypneic breathing patterns like
Cushing's.
Hint: Analyze the components of the vital sign changes. A wide gap between systolic
and diastolic pressure combined with a slow heart rate is a classic skull-pressure alarm.
Question 5 (Topic: Respiratory / Collaborative Care)
A patient with a history of severe chronic obstructive pulmonary disease (COPD) is
admitted with acute respiratory failure and placed on noninvasive positive pressure
ventilation (BiPAP). Which assessment finding requires immediate notification of the
healthcare provider?
A) A persistent, productive cough with thick, clear sputum.
B) Somnolence, confusion, and inability to cooperate with the BiPAP mask.
C) An arterial blood gas (ABG) showing a pH of 7.35 and PaCO2 of 52 mmHg.
D) Patient complaints of a dry mouth and nasal irritation.
Correct Answer: B
Rationale:
Why B is correct: To safely use BiPAP, a patient must be alert, cooperative, and able
to maintain their own airway. Increased somnolence and confusion indicate worsening
hypercapnia (CO2 retention) and failure of noninvasive therapy, necessitating urgent
endotracheal intubation.
Why A is incorrect: Sputum production is expected in chronic bronchitis/COPD and
does not indicate an acute failure of the BiPAP system.
Question 6 (Topic: Renal / Fluid & Electrolytes)
A patient with chronic kidney disease (CKD) missed their last two hemodialysis
sessions. The morning EKG reveals tall, peaked T waves and a widened QRS complex.
Which medication should the nurse anticipate administering first to stabilize the
myocardial cell membrane?
A) Sodium polystyrene sulfonate (Kayexalate) orally
B) 10% Calcium gluconate intravenously
C) Regular insulin and 50% Dextrose intravenously
D) Furosemide (Lasix) intravenously
Correct Answer: B
Rationale:
Clinical Judgment and Collaborative Care 11th edition by
Donna D. Ignatavicius ISBN: 978-0323878265 NEW
COMPLETE GUIDE WITH RATIONALES 100% VERIFIED A+
GRADE ASSURED!!!!NEW LATEST UPDATE
1 (Topic: Advanced Hematology / QSEN Safety)
A nurse is preparing to administer an intravenous infusion of heparin to a patient with a
massive deep vein thrombosis (DVT). The patient's baseline activated partial
thromboplastin time (aPTT) is 30 seconds. Which action by the nurse best reflects the
QSEN competency of Evidence-Based Practice and Safety?
, A) Adjusting the infusion rate based on the patient's subjective report of leg pain
reduction.
B) Setting the infusion pump to deliver the heparin dose without a secondary nurse
verification.
C) Utilizing a standardized, weight-based heparin protocol to titrate the dose based on
serial aPTT values.
D) Administering the heparin via a gravity infusion set to ensure rapid delivery.
Correct Answer: C
Rationale:
Why C is correct: Standardized, weight-based heparin protocols are evidence-based
tools proven to safely achieve therapeutic anticoagulation ranges quickly while
minimizing bleeding risks. Serial aPTT tracking ensures precise titration.
Question 2 (Topic: Endocrine / Prioritization)
A patient with a history of primary hyperparathyroidism is admitted to the medical unit.
The nurse reviews the morning laboratory results and notes a serum calcium level of
14.2 mg/dL. Which collaborative intervention should the nurse prioritize first?
A) Initiating an intravenous infusion of 0.9% Normal Saline at 200 mL/hr.
B) Administering oral calcium carbonate supplements with meals.
C) Preparing the patient for an immediate diagnostic parathyroid scan.
D) Encouraging strict bed rest to prevent pathological fractures.
Correct Answer: A
Rationale:
Why A is correct: A serum calcium level of 14.2 mg/dL indicates severe hypercalcemia
(normal: 9.0–10.5 mg/dL), a medical emergency. The priority treatment is aggressive
fluid volume repletion with isotonic saline to promote renal calcium excretion and
prevent acute kidney injury.
Question 3 (Topic: Gastrointestinal / Hepatic Care)
A nurse is evaluating a patient with advanced cirrhosis who is receiving lactulose for
hepatic encephalopathy. Which finding indicates that the medication is achieving its
therapeutic goal?
, A) The patient has four soft, formed bowel movements per day.
B) The patient demonstrates increased orientation and decreased asterixis.
C) The patient's serum alanine aminotransferase (ALT) level returns to normal.
D) The patient's abdominal girth decreases by 2 centimeters.
Correct Answer: B
Rationale:
Why B is correct: Lactulose works by trapping ammonia in the gut and expelling it
through the stool. The primary therapeutic goal is the resolution of hepatic
encephalopathy, indicated by improved neurological status (orientation) and a decrease
in asterixis (liver flap).
Why A is incorrect: While lactulose causes loose stools, having four formed stools is a
secondary mechanical side effect, not the primary therapeutic metabolic metric.
Why C is incorrect: Lactulose treats the complication of liver failure (ammonia
buildup); it does not cure the underlying liver disease or lower liver enzymes like ALT.
Why D is incorrect: Reduction in abdominal girth relates to the management of ascites
(via diuretics/paracentesis), not lactulose therapy.
Hint: Focus on the specific organ system targeted by ammonia toxicity. The therapeutic
effect will always present as a change in that system.
Question 4 (Topic: Neurological Clinical Judgment)
A patient who sustained a traumatic brain injury (TBI) is being monitored in the
neurological intensive care unit. The nurse notices the patient's blood pressure has
shifted from 122/80 mmHg to 168/54 mmHg, the pulse has dropped from 78 to 48
beats/minute, and respirations are irregular. How should the nurse interpret these
findings?
A) The patient is experiencing severe hypovolemic shock.
B) The patient's condition is improving, and sedation can be safely reduced.
C) The patient is exhibiting Cushing's Triad, indicating imminent brain herniation.
D) The patient has developed autonomic dysreflexia from a spinal injury.
Correct Answer: C
Rationale:
Why C is correct: Widening pulse pressure (systolic hypertension), bradycardia, and
irregular respirations comprise Cushing's Triad. This is a late sign of drastically
increased intracranial pressure (ICP) and signals imminent brainstem herniation,
requiring immediate intervention.
Why A is incorrect: Hypovolemic shock presents with hypotension and tachycardia,
the exact opposite of these findings.
, Why B is incorrect: This is a neurological emergency pointing to a life-threatening
decline, not an improvement.
Why D is incorrect: Autonomic dysreflexia features severe hypertension and
bradycardia, but it typically occurs in patients with spinal cord injuries at or above T6,
and it does not characteristically cause irregular, bradypneic breathing patterns like
Cushing's.
Hint: Analyze the components of the vital sign changes. A wide gap between systolic
and diastolic pressure combined with a slow heart rate is a classic skull-pressure alarm.
Question 5 (Topic: Respiratory / Collaborative Care)
A patient with a history of severe chronic obstructive pulmonary disease (COPD) is
admitted with acute respiratory failure and placed on noninvasive positive pressure
ventilation (BiPAP). Which assessment finding requires immediate notification of the
healthcare provider?
A) A persistent, productive cough with thick, clear sputum.
B) Somnolence, confusion, and inability to cooperate with the BiPAP mask.
C) An arterial blood gas (ABG) showing a pH of 7.35 and PaCO2 of 52 mmHg.
D) Patient complaints of a dry mouth and nasal irritation.
Correct Answer: B
Rationale:
Why B is correct: To safely use BiPAP, a patient must be alert, cooperative, and able
to maintain their own airway. Increased somnolence and confusion indicate worsening
hypercapnia (CO2 retention) and failure of noninvasive therapy, necessitating urgent
endotracheal intubation.
Why A is incorrect: Sputum production is expected in chronic bronchitis/COPD and
does not indicate an acute failure of the BiPAP system.
Question 6 (Topic: Renal / Fluid & Electrolytes)
A patient with chronic kidney disease (CKD) missed their last two hemodialysis
sessions. The morning EKG reveals tall, peaked T waves and a widened QRS complex.
Which medication should the nurse anticipate administering first to stabilize the
myocardial cell membrane?
A) Sodium polystyrene sulfonate (Kayexalate) orally
B) 10% Calcium gluconate intravenously
C) Regular insulin and 50% Dextrose intravenously
D) Furosemide (Lasix) intravenously
Correct Answer: B
Rationale:
