Test Bank for Ignatavicius' Medical-Surgical
Nursing| 12th Edition | 2026 Edition |Answers +
Rational | All Chapters Covered
Cherie R. Rebar, PhD, MBA, RN, CNE, CNEcl, COI, FAADN and Nicole M. Heimgartner, DNP, RN,
,UNIT I: Essential Concepts of Medical-Surgical Nursing
Chapter 1. Overview of Professional Nursing Concepts for Medical-
Surgical Nursing
1. A nurse is caring for a 72-year-old patient admitted to a medical-surgical unit with
pneumonia. During the initial assessment, the patient becomes increasingly confused
and has a respiratory rate of 30/min, oxygen saturation of 86% on room air, and a heart
rate of 118/min. The patient states, "I am fine. Please leave me alone." Which action
should the nurse take first?
A. Ask the patient about preferences for the timing of respiratory treatments
B. Apply oxygen as prescribed and rapidly reassess the patient's respiratory status
C. Document the patient's refusal of treatment and return after the patient rests
D. Contact the patient's family to determine the patient's usual behavior
ANS: B
Rationale: The patient's acute confusion, tachypnea, tachycardia, and oxygen saturation of 86%
indicate significant hypoxemia and possible clinical deterioration. The nurse's first responsibility
is to recognize the threat to physiologic stability and intervene to support oxygenation. Applying
oxygen as prescribed and reassessing the patient's response addresses the immediate threat
while allowing the nurse to determine whether additional escalation is required. Patient-
centered care remains important, but patient preferences do not eliminate the nurse's
responsibility to respond to an immediately life-threatening physiologic problem. Documenting
the refusal without addressing the hypoxemia is unsafe. Contacting the family may provide
useful information later but does not address the immediate problem.
2. A medical-surgical nurse is caring for four patients. Which patient should the nurse
assess first?
A. A patient with heart failure who reports a 2-kg weight gain over the past week
B. A patient with diabetes who has a blood glucose level of 186 mg/dL before lunch
C. A patient receiving a blood transfusion who develops chills, dyspnea, and low back pain
D. A patient with osteoarthritis who reports pain of 7/10 before receiving a prescribed analgesic
ANS: C
Rationale: Chills, dyspnea, and low back pain during a blood transfusion are concerning for an
acute transfusion reaction, which can progress rapidly to hemolysis, shock, renal injury, and
disseminated intravascular coagulation. The nurse should immediately stop the transfusion
according to institutional protocol and initiate appropriate emergency management. The other
findings require nursing attention but are not as immediately life threatening. A gradual weight
gain in heart failure suggests worsening fluid retention, but it does not take priority over a
possible acute transfusion reaction. A glucose level of 186 mg/dL requires management
according to the patient's treatment plan but is not the highest priority. Severe osteoarthritis
pain requires treatment, but pain without evidence of an immediately life-threatening condition
is lower priority.
, 3. A nurse is preparing to administer medications to a patient who has been hospitalized
for acute kidney injury. The nurse notices that one medication dose is substantially
higher than the dose listed in the patient's previous medication record. The electronic
medication administration system does not display an alert. Which action is most
appropriate?
A. Administer the medication because the electronic system did not identify an error
B. Ask another nurse to administer the medication instead
C. Hold the medication and verify the prescription with the appropriate prescriber or
pharmacist
D. Administer the medication and document the discrepancy after the patient's treatment
ANS: C
Rationale: The nurse remains accountable for safe medication administration even when
electronic systems do not identify a potential error. Acute kidney injury can substantially alter
medication clearance and increase the risk of toxicity for drugs that are renally eliminated. A
markedly different dose should therefore be investigated before administration. The nurse
should hold the medication and clarify the prescription with the appropriate prescriber or
pharmacist. Technology supports clinical practice but does not replace professional nursing
judgment. Asking another nurse to administer a questionable medication does not resolve the
safety concern. Administering the medication before clarification creates an avoidable risk of
harm.
4. A nurse is caring for a patient who has limited English proficiency and is preparing for a
procedure. The patient's adult daughter offers to interpret the nurse's explanation of the
procedure. Which action by the nurse best demonstrates patient-centered and safe
professional nursing practice?
A. Accept the daughter's assistance because the daughter knows the patient's medical history
B. Use a qualified medical interpreter and communicate directly with the patient
C. Ask the daughter to translate only the information that the patient does not understand
D. Provide written instructions in English and ask the daughter to explain them later
ANS: B
Rationale: A qualified medical interpreter promotes accurate communication, informed
decision-making, confidentiality, and patient autonomy. The nurse should speak directly to the
patient rather than directing communication toward the interpreter. Family members may
unintentionally omit, alter, or filter information and may not understand medical terminology
accurately. Reliance on a family member can also create privacy and role-related concerns.
Written information in English is insufficient when the patient cannot adequately understand
the language. Patient-centered care requires communication that accommodates the patient's
language needs and supports the patient's participation in decisions.
5. A nurse is caring for a patient who has newly diagnosed heart failure. The patient states,
"I do not understand what is happening to me, and I am scared that I will die." Which
response by the nurse best demonstrates therapeutic communication and patient-
centered care?
, A. "You should try not to worry because many patients recover from heart failure."
B. "Your provider will explain everything to you during rounds."
C. "Tell me what concerns you most about your diagnosis and what you would like to
understand."
D. "You need to focus on following your treatment plan rather than worrying about the
diagnosis."
ANS: C
Rationale: The response invites the patient to identify specific concerns, values, and
information needs. Patient-centered care requires the nurse to recognize the patient as an
active participant in care rather than simply providing instructions. Asking an open-ended
question allows the nurse to assess the patient's understanding, emotional response, priorities,
and readiness to learn. Reassuring the patient that everything will be fine may minimize
legitimate concerns and provides false reassurance. Referring the patient entirely to the
provider ignores the nurse's role in education and psychosocial support. Telling the patient not
to worry dismisses the emotional component of the illness rather than addressing it.
6. A nurse on a medical-surgical unit notices that patients who receive intravenous
medications through a particular type of infusion pump have experienced several
programming errors during the past month. The nurse suspects that the problem is
related to the pump interface. Which action best reflects quality improvement
principles?
A. Immediately replace all pumps without collecting additional information
B. Report the concern and participate in reviewing the pattern of errors and contributing factors
C. Instruct nurses to be more careful when programming the pumps
D. Document the errors only in the individual patients' medical records
ANS: B
Rationale: Quality improvement uses a systematic approach to identify patterns, examine
contributing factors, and implement and evaluate changes designed to improve care. Multiple
similar medication administration errors suggest a potential system issue rather than simply
individual nurse performance. The nurse should report the concern through the appropriate
organizational process and participate in analysis of the events. Replacing equipment without
investigating the problem may fail to identify the underlying cause. Telling nurses to be more
careful does not address possible design, training, workflow, or system contributors.
Documentation in individual medical records is necessary when clinically appropriate but does
not by itself initiate organizational improvement.
7. A patient with newly diagnosed cancer tells the nurse, "I do not want my family to know
anything about my diagnosis." Later, the patient's adult son asks the nurse, "What did
the biopsy show?" Which response by the nurse is most appropriate?
A. "The biopsy confirmed the diagnosis, but your parent does not want to discuss it."
B. "You are the patient's son, so I can tell you what I know."
C. "I cannot provide information about your parent's health without the patient's permission."
D. "You should ask the oncologist because nurses cannot discuss biopsy results."
ANS: C
Nursing| 12th Edition | 2026 Edition |Answers +
Rational | All Chapters Covered
Cherie R. Rebar, PhD, MBA, RN, CNE, CNEcl, COI, FAADN and Nicole M. Heimgartner, DNP, RN,
,UNIT I: Essential Concepts of Medical-Surgical Nursing
Chapter 1. Overview of Professional Nursing Concepts for Medical-
Surgical Nursing
1. A nurse is caring for a 72-year-old patient admitted to a medical-surgical unit with
pneumonia. During the initial assessment, the patient becomes increasingly confused
and has a respiratory rate of 30/min, oxygen saturation of 86% on room air, and a heart
rate of 118/min. The patient states, "I am fine. Please leave me alone." Which action
should the nurse take first?
A. Ask the patient about preferences for the timing of respiratory treatments
B. Apply oxygen as prescribed and rapidly reassess the patient's respiratory status
C. Document the patient's refusal of treatment and return after the patient rests
D. Contact the patient's family to determine the patient's usual behavior
ANS: B
Rationale: The patient's acute confusion, tachypnea, tachycardia, and oxygen saturation of 86%
indicate significant hypoxemia and possible clinical deterioration. The nurse's first responsibility
is to recognize the threat to physiologic stability and intervene to support oxygenation. Applying
oxygen as prescribed and reassessing the patient's response addresses the immediate threat
while allowing the nurse to determine whether additional escalation is required. Patient-
centered care remains important, but patient preferences do not eliminate the nurse's
responsibility to respond to an immediately life-threatening physiologic problem. Documenting
the refusal without addressing the hypoxemia is unsafe. Contacting the family may provide
useful information later but does not address the immediate problem.
2. A medical-surgical nurse is caring for four patients. Which patient should the nurse
assess first?
A. A patient with heart failure who reports a 2-kg weight gain over the past week
B. A patient with diabetes who has a blood glucose level of 186 mg/dL before lunch
C. A patient receiving a blood transfusion who develops chills, dyspnea, and low back pain
D. A patient with osteoarthritis who reports pain of 7/10 before receiving a prescribed analgesic
ANS: C
Rationale: Chills, dyspnea, and low back pain during a blood transfusion are concerning for an
acute transfusion reaction, which can progress rapidly to hemolysis, shock, renal injury, and
disseminated intravascular coagulation. The nurse should immediately stop the transfusion
according to institutional protocol and initiate appropriate emergency management. The other
findings require nursing attention but are not as immediately life threatening. A gradual weight
gain in heart failure suggests worsening fluid retention, but it does not take priority over a
possible acute transfusion reaction. A glucose level of 186 mg/dL requires management
according to the patient's treatment plan but is not the highest priority. Severe osteoarthritis
pain requires treatment, but pain without evidence of an immediately life-threatening condition
is lower priority.
, 3. A nurse is preparing to administer medications to a patient who has been hospitalized
for acute kidney injury. The nurse notices that one medication dose is substantially
higher than the dose listed in the patient's previous medication record. The electronic
medication administration system does not display an alert. Which action is most
appropriate?
A. Administer the medication because the electronic system did not identify an error
B. Ask another nurse to administer the medication instead
C. Hold the medication and verify the prescription with the appropriate prescriber or
pharmacist
D. Administer the medication and document the discrepancy after the patient's treatment
ANS: C
Rationale: The nurse remains accountable for safe medication administration even when
electronic systems do not identify a potential error. Acute kidney injury can substantially alter
medication clearance and increase the risk of toxicity for drugs that are renally eliminated. A
markedly different dose should therefore be investigated before administration. The nurse
should hold the medication and clarify the prescription with the appropriate prescriber or
pharmacist. Technology supports clinical practice but does not replace professional nursing
judgment. Asking another nurse to administer a questionable medication does not resolve the
safety concern. Administering the medication before clarification creates an avoidable risk of
harm.
4. A nurse is caring for a patient who has limited English proficiency and is preparing for a
procedure. The patient's adult daughter offers to interpret the nurse's explanation of the
procedure. Which action by the nurse best demonstrates patient-centered and safe
professional nursing practice?
A. Accept the daughter's assistance because the daughter knows the patient's medical history
B. Use a qualified medical interpreter and communicate directly with the patient
C. Ask the daughter to translate only the information that the patient does not understand
D. Provide written instructions in English and ask the daughter to explain them later
ANS: B
Rationale: A qualified medical interpreter promotes accurate communication, informed
decision-making, confidentiality, and patient autonomy. The nurse should speak directly to the
patient rather than directing communication toward the interpreter. Family members may
unintentionally omit, alter, or filter information and may not understand medical terminology
accurately. Reliance on a family member can also create privacy and role-related concerns.
Written information in English is insufficient when the patient cannot adequately understand
the language. Patient-centered care requires communication that accommodates the patient's
language needs and supports the patient's participation in decisions.
5. A nurse is caring for a patient who has newly diagnosed heart failure. The patient states,
"I do not understand what is happening to me, and I am scared that I will die." Which
response by the nurse best demonstrates therapeutic communication and patient-
centered care?
, A. "You should try not to worry because many patients recover from heart failure."
B. "Your provider will explain everything to you during rounds."
C. "Tell me what concerns you most about your diagnosis and what you would like to
understand."
D. "You need to focus on following your treatment plan rather than worrying about the
diagnosis."
ANS: C
Rationale: The response invites the patient to identify specific concerns, values, and
information needs. Patient-centered care requires the nurse to recognize the patient as an
active participant in care rather than simply providing instructions. Asking an open-ended
question allows the nurse to assess the patient's understanding, emotional response, priorities,
and readiness to learn. Reassuring the patient that everything will be fine may minimize
legitimate concerns and provides false reassurance. Referring the patient entirely to the
provider ignores the nurse's role in education and psychosocial support. Telling the patient not
to worry dismisses the emotional component of the illness rather than addressing it.
6. A nurse on a medical-surgical unit notices that patients who receive intravenous
medications through a particular type of infusion pump have experienced several
programming errors during the past month. The nurse suspects that the problem is
related to the pump interface. Which action best reflects quality improvement
principles?
A. Immediately replace all pumps without collecting additional information
B. Report the concern and participate in reviewing the pattern of errors and contributing factors
C. Instruct nurses to be more careful when programming the pumps
D. Document the errors only in the individual patients' medical records
ANS: B
Rationale: Quality improvement uses a systematic approach to identify patterns, examine
contributing factors, and implement and evaluate changes designed to improve care. Multiple
similar medication administration errors suggest a potential system issue rather than simply
individual nurse performance. The nurse should report the concern through the appropriate
organizational process and participate in analysis of the events. Replacing equipment without
investigating the problem may fail to identify the underlying cause. Telling nurses to be more
careful does not address possible design, training, workflow, or system contributors.
Documentation in individual medical records is necessary when clinically appropriate but does
not by itself initiate organizational improvement.
7. A patient with newly diagnosed cancer tells the nurse, "I do not want my family to know
anything about my diagnosis." Later, the patient's adult son asks the nurse, "What did
the biopsy show?" Which response by the nurse is most appropriate?
A. "The biopsy confirmed the diagnosis, but your parent does not want to discuss it."
B. "You are the patient's son, so I can tell you what I know."
C. "I cannot provide information about your parent's health without the patient's permission."
D. "You should ask the oncologist because nurses cannot discuss biopsy results."
ANS: C
