Medical-Surgical Nursing: Concepts
for Clinical Judgment and
Collaborative Care 11th Edition Test
Bank | Donna D. Ignatavicius, Cherie
R. Rebar & Nicole M. Heimgartner |
Comprehensive Practice Questions
with Rationales | NCLEX® Exam Prep
Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative
Care (11th Edition) - NCLEX® Exam Prep
• Comprehensive question practice exam covering all units and chapters from
the Ignatavicius & Rebar textbook, designed to assess clinical judgment and
collaborative care competencies required for NCLEX® success.
• Study strategy: Work through questions systematically by chapter unit, review
detailed rationales to strengthen understanding of pathophysiology and nursing
interventions, and identify weak areas for targeted review before high-stakes
exams.
1. A 65-year-old patient admitted with hypertensive crisis presents with
severe headache, vision changes, and elevated blood pressure of 210/120
mmHg. Which immediate nursing action demonstrates appropriate clinical
judgment?
A) Administer antihypertensive medication and recheck BP in 4 hours
B) Notify the provider immediately and prepare for continuous cardiac monitoring
C) Place patient in supine position to promote relaxation
D) Restrict all fluids to reduce circulating volume
E) Encourage deep breathing exercises to naturally lower BP
✓ CORRECT ANSWER: B) Notify the provider immediately and prepare for
continuous cardiac monitoring
,Rationale: A BP of 210/120 mmHg with neurological symptoms (headache, vision
changes) indicates hypertensive emergency requiring immediate intervention.
Continuous cardiac monitoring is essential to detect complications such as
myocardial infarction or dysrhythmias. The provider must be notified immediately
for emergency treatment protocols. Simply administering medication without
provider notification delays critical care, supine positioning increases intracranial
pressure, fluid restriction alone is insufficient, and breathing exercises are
inadequate for hypertensive crisis management.
2. A patient with acute coronary syndrome (ACS) is receiving dual antiplatelet
therapy. Which patient statement indicates a need for additional education
regarding medication compliance?
A) "I will take aspirin and clopidogrel exactly as prescribed without skipping doses"
B) "I can stop taking these medications once my chest pain resolves"
C) "I should report any unusual bleeding or bruising to my provider"
D) "I will avoid NSAIDs while taking these antiplatelet medications"
E) "I need to keep all follow-up appointments to monitor my progress"
✓ CORRECT ANSWER: B) I can stop taking these medications once my chest
pain resolves
Rationale: Dual antiplatelet therapy must continue for the prescribed duration
(typically 6-12 months post-stent placement) to prevent stent thrombosis and
recurrent ACS, regardless of symptom resolution. Stopping medications
prematurely significantly increases risk of myocardial infarction and death. All other
statements demonstrate appropriate understanding: maintaining prescribed
dosing, reporting bleeding complications, avoiding NSAIDs which potentiate
bleeding, and attending follow-up appointments are correct behaviors.
3. A 58-year-old patient with COPD presents with increased shortness of
breath, change in sputum color to yellow-green, and low oxygen saturation
,(88% on room air). Which collaborative intervention should the nurse
prioritize?
A) Place patient on continuous pulse oximetry and initiate oxygen therapy
B) Prepare sputum specimen for culture and sensitivity and contact provider
regarding antibiotic therapy
C) Administer bronchodilators and arrange for pulmonary function testing
D) Insert a peripheral IV line for fluid replacement
E) Perform chest physiotherapy and position in high Fowler's position
✓ CORRECT ANSWER: B) Prepare sputum specimen for culture and sensitivity
and contact provider regarding antibiotic therapy
Rationale: The clinical presentation (color change of sputum, increased dyspnea,
low O2 sat) indicates COPD exacerbation with bacterial infection. Obtaining culture
and sensitivity before antibiotic therapy ensures targeted treatment and improved
outcomes. Contacting the provider is essential for collaborative decision-making
regarding antibiotic selection. While oxygen therapy (A) is important, it doesn't
address the underlying infection. Bronchodilators (C) are supportive but secondary
to identifying and treating infection. IV fluids (D) and chest physiotherapy (E) are
adjunctive measures, not priorities in this acute situation.
4. A 42-year-old patient with Type 2 diabetes presents with fasting glucose of
240 mg/dL and reports increased thirst, frequent urination, and fatigue for 3
days. Which assessment finding is most concerning and requires immediate
intervention?
A) Fasting glucose level of 240 mg/dL
B) Patient report of polyuria and polydipsia
C) Presence of moderate ketones in urine with venous pH of 7.28
D) Patient stating "I haven't been checking my blood glucose regularly"
E) HbA1c level of 9.5% indicating poor glycemic control
, ✓ CORRECT ANSWER: C) Presence of moderate ketones in urine with venous
pH of 7.28
Rationale: Moderate ketones with acidemia (pH 7.28) indicates diabetic
ketoacidosis (DKA), a life-threatening emergency requiring immediate intervention
including IV fluids, insulin, electrolyte monitoring, and possible ICU admission.
While elevated fasting glucose (A) and HbA1c (E) indicate poor control, they are not
immediately life-threatening. Polyuria and polydipsia (B) are expected symptoms of
hyperglycemia. Non-adherence (D) requires education but is not acutely dangerous.
The combination of ketosis with acidemia represents metabolic derangement
requiring emergency treatment.
5. A post-operative patient 4 hours after abdominal surgery has a nasogastric
(NG) tube connected to low intermittent suction. The patient reports feeling
nauseated and the nurse observes that the NG tube has not draining for the
past 2 hours. What is the most appropriate nursing action?
A) Document the finding and check again in 1 hour
B) Assume the tube is functioning properly since it was just placed
C) Assess tube placement, evaluate patency, and notify the provider if obstruction is
suspected
D) Increase the suction setting to high continuous to promote drainage
E) Remove the tube immediately as it is no longer functioning
✓ CORRECT ANSWER: C) Assess tube placement, evaluate patency, and notify
the provider if obstruction is suspected
Rationale: Lack of NG output combined with nausea indicates potential tube
malposition or obstruction, which requires immediate assessment. The nurse
should verify tube placement (auscultate air into tube), assess for kinks or
obstruction, and notify the provider if patency cannot be restored. Waiting (A)
delays intervention and patient may vomit. The tube was just placed but placement
must be verified (B is incorrect). Increasing suction to high (D) can cause mucosal
for Clinical Judgment and
Collaborative Care 11th Edition Test
Bank | Donna D. Ignatavicius, Cherie
R. Rebar & Nicole M. Heimgartner |
Comprehensive Practice Questions
with Rationales | NCLEX® Exam Prep
Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative
Care (11th Edition) - NCLEX® Exam Prep
• Comprehensive question practice exam covering all units and chapters from
the Ignatavicius & Rebar textbook, designed to assess clinical judgment and
collaborative care competencies required for NCLEX® success.
• Study strategy: Work through questions systematically by chapter unit, review
detailed rationales to strengthen understanding of pathophysiology and nursing
interventions, and identify weak areas for targeted review before high-stakes
exams.
1. A 65-year-old patient admitted with hypertensive crisis presents with
severe headache, vision changes, and elevated blood pressure of 210/120
mmHg. Which immediate nursing action demonstrates appropriate clinical
judgment?
A) Administer antihypertensive medication and recheck BP in 4 hours
B) Notify the provider immediately and prepare for continuous cardiac monitoring
C) Place patient in supine position to promote relaxation
D) Restrict all fluids to reduce circulating volume
E) Encourage deep breathing exercises to naturally lower BP
✓ CORRECT ANSWER: B) Notify the provider immediately and prepare for
continuous cardiac monitoring
,Rationale: A BP of 210/120 mmHg with neurological symptoms (headache, vision
changes) indicates hypertensive emergency requiring immediate intervention.
Continuous cardiac monitoring is essential to detect complications such as
myocardial infarction or dysrhythmias. The provider must be notified immediately
for emergency treatment protocols. Simply administering medication without
provider notification delays critical care, supine positioning increases intracranial
pressure, fluid restriction alone is insufficient, and breathing exercises are
inadequate for hypertensive crisis management.
2. A patient with acute coronary syndrome (ACS) is receiving dual antiplatelet
therapy. Which patient statement indicates a need for additional education
regarding medication compliance?
A) "I will take aspirin and clopidogrel exactly as prescribed without skipping doses"
B) "I can stop taking these medications once my chest pain resolves"
C) "I should report any unusual bleeding or bruising to my provider"
D) "I will avoid NSAIDs while taking these antiplatelet medications"
E) "I need to keep all follow-up appointments to monitor my progress"
✓ CORRECT ANSWER: B) I can stop taking these medications once my chest
pain resolves
Rationale: Dual antiplatelet therapy must continue for the prescribed duration
(typically 6-12 months post-stent placement) to prevent stent thrombosis and
recurrent ACS, regardless of symptom resolution. Stopping medications
prematurely significantly increases risk of myocardial infarction and death. All other
statements demonstrate appropriate understanding: maintaining prescribed
dosing, reporting bleeding complications, avoiding NSAIDs which potentiate
bleeding, and attending follow-up appointments are correct behaviors.
3. A 58-year-old patient with COPD presents with increased shortness of
breath, change in sputum color to yellow-green, and low oxygen saturation
,(88% on room air). Which collaborative intervention should the nurse
prioritize?
A) Place patient on continuous pulse oximetry and initiate oxygen therapy
B) Prepare sputum specimen for culture and sensitivity and contact provider
regarding antibiotic therapy
C) Administer bronchodilators and arrange for pulmonary function testing
D) Insert a peripheral IV line for fluid replacement
E) Perform chest physiotherapy and position in high Fowler's position
✓ CORRECT ANSWER: B) Prepare sputum specimen for culture and sensitivity
and contact provider regarding antibiotic therapy
Rationale: The clinical presentation (color change of sputum, increased dyspnea,
low O2 sat) indicates COPD exacerbation with bacterial infection. Obtaining culture
and sensitivity before antibiotic therapy ensures targeted treatment and improved
outcomes. Contacting the provider is essential for collaborative decision-making
regarding antibiotic selection. While oxygen therapy (A) is important, it doesn't
address the underlying infection. Bronchodilators (C) are supportive but secondary
to identifying and treating infection. IV fluids (D) and chest physiotherapy (E) are
adjunctive measures, not priorities in this acute situation.
4. A 42-year-old patient with Type 2 diabetes presents with fasting glucose of
240 mg/dL and reports increased thirst, frequent urination, and fatigue for 3
days. Which assessment finding is most concerning and requires immediate
intervention?
A) Fasting glucose level of 240 mg/dL
B) Patient report of polyuria and polydipsia
C) Presence of moderate ketones in urine with venous pH of 7.28
D) Patient stating "I haven't been checking my blood glucose regularly"
E) HbA1c level of 9.5% indicating poor glycemic control
, ✓ CORRECT ANSWER: C) Presence of moderate ketones in urine with venous
pH of 7.28
Rationale: Moderate ketones with acidemia (pH 7.28) indicates diabetic
ketoacidosis (DKA), a life-threatening emergency requiring immediate intervention
including IV fluids, insulin, electrolyte monitoring, and possible ICU admission.
While elevated fasting glucose (A) and HbA1c (E) indicate poor control, they are not
immediately life-threatening. Polyuria and polydipsia (B) are expected symptoms of
hyperglycemia. Non-adherence (D) requires education but is not acutely dangerous.
The combination of ketosis with acidemia represents metabolic derangement
requiring emergency treatment.
5. A post-operative patient 4 hours after abdominal surgery has a nasogastric
(NG) tube connected to low intermittent suction. The patient reports feeling
nauseated and the nurse observes that the NG tube has not draining for the
past 2 hours. What is the most appropriate nursing action?
A) Document the finding and check again in 1 hour
B) Assume the tube is functioning properly since it was just placed
C) Assess tube placement, evaluate patency, and notify the provider if obstruction is
suspected
D) Increase the suction setting to high continuous to promote drainage
E) Remove the tube immediately as it is no longer functioning
✓ CORRECT ANSWER: C) Assess tube placement, evaluate patency, and notify
the provider if obstruction is suspected
Rationale: Lack of NG output combined with nausea indicates potential tube
malposition or obstruction, which requires immediate assessment. The nurse
should verify tube placement (auscultate air into tube), assess for kinks or
obstruction, and notify the provider if patency cannot be restored. Waiting (A)
delays intervention and patient may vomit. The tube was just placed but placement
must be verified (B is incorrect). Increasing suction to high (D) can cause mucosal
