Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
1
Reference: Ch. 1: Roles & Responsibilities of the Medical-
Surgical Nurse — Nursing Process/Clinical Judgment
Question stem: A 68-year-old postoperative patient who had an
open colectomy is receiving PCA (patient-controlled analgesia).
The nurse notes the patient is drowsy, RR 8 breaths/min, and
SpO₂ 90% on room air. Using the nursing process, what is the
nurse’s priority action?
A. Document findings and continue to monitor every 15
minutes.
B. Stop the PCA infusion and stimulate the patient to breathe.
C. Notify the surgeon and request transfer to ICU.
D. Administer naloxone per protocol and reassess respiratory
status.
Correct answer: B
Rationales:
, • Correct (B): Immediate bedside safety action is to stop the
opioid infusion and stimulate the patient to protect airway
and respirations—this is the priority intervention before
escalation.
• A (incorrect): Continued monitoring without immediate
intervention risks respiratory arrest.
• C (incorrect): Notifying the surgeon may be necessary after
immediate actions, but it is not the first priority.
• D (incorrect): Administering naloxone may be indicated if
patient fails to respond to stimulation or if protocol
requires it, but initial action is to stop infusion and attempt
to arouse/ventilate; naloxone is subsequent if respiratory
depression persists.
Teaching point: Immediate bedside interventions to
restore airway/respiration trump documentation or
escalation.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Roles & Responsibilities
2
Reference: Ch. 1: Clinical Judgment & Prioritization — ADPIE
focus
Question stem: A nurse is planning care for four medical-
surgical patients. Which patient should the nurse assess first
during morning rounds?
,A. A patient with Type 2 diabetes scheduled for discharge today
who needs insulin teaching.
B. A post-op patient 2 hours post laparotomy with moderate
serosanguineous drainage on the dressing.
C. A patient with CHF reporting sudden weight gain of 0.5 kg
overnight.
D. A patient on telemetry who had one premature ventricular
contraction (PVC) overnight and is asymptomatic.
Correct answer: C
Rationales:
• Correct (C): Sudden weight gain suggests acute fluid
retention and possible decompensated heart failure—
requires immediate assessment and intervention.
• A (incorrect): Discharge teaching is important but not
time-sensitive compared to possible acute CHF
exacerbation.
• B (incorrect): Moderate serosanguineous drainage 2 hours
post-op is expected; persistent hemorrhage or large bright
red bleeding would be higher priority.
• D (incorrect): An isolated PVC in an asymptomatic patient
is lower priority than signs of acute fluid overload.
Teaching point: Prioritize patients showing signs of acute
physiologic instability.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Clinical Judgment
, 3
Reference: Ch. 1: Delegation & Collaboration — Scope of
Practice
Question stem: The RN delegates a stable postoperative
patient’s vital signs and pain score to a licensed practical nurse
(LPN). Which task must the RN retain and not delegate?
A. Instructing the LPN to record pain scores every 4 hours.
B. Performing the initial postoperative assessment including
neurovascular checks.
C. Requesting the LPN to administer PRN acetaminophen per
order.
D. Asking the LPN to report any abnormal findings immediately.
Correct answer: B
Rationales:
• Correct (B): Initial comprehensive assessments and the
identification of problems requiring independent nursing
judgment should be performed by the RN.
• A (incorrect): Recording pain scores is within LPN abilities
under RN delegation.
• C (incorrect): Medication administration per protocol may
be delegated depending on facility policy and LPN scope.
• D (incorrect): LPNs should report abnormalities—this is
appropriate delegation.
Teaching point: RNs retain initial comprehensive
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
1
Reference: Ch. 1: Roles & Responsibilities of the Medical-
Surgical Nurse — Nursing Process/Clinical Judgment
Question stem: A 68-year-old postoperative patient who had an
open colectomy is receiving PCA (patient-controlled analgesia).
The nurse notes the patient is drowsy, RR 8 breaths/min, and
SpO₂ 90% on room air. Using the nursing process, what is the
nurse’s priority action?
A. Document findings and continue to monitor every 15
minutes.
B. Stop the PCA infusion and stimulate the patient to breathe.
C. Notify the surgeon and request transfer to ICU.
D. Administer naloxone per protocol and reassess respiratory
status.
Correct answer: B
Rationales:
, • Correct (B): Immediate bedside safety action is to stop the
opioid infusion and stimulate the patient to protect airway
and respirations—this is the priority intervention before
escalation.
• A (incorrect): Continued monitoring without immediate
intervention risks respiratory arrest.
• C (incorrect): Notifying the surgeon may be necessary after
immediate actions, but it is not the first priority.
• D (incorrect): Administering naloxone may be indicated if
patient fails to respond to stimulation or if protocol
requires it, but initial action is to stop infusion and attempt
to arouse/ventilate; naloxone is subsequent if respiratory
depression persists.
Teaching point: Immediate bedside interventions to
restore airway/respiration trump documentation or
escalation.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Roles & Responsibilities
2
Reference: Ch. 1: Clinical Judgment & Prioritization — ADPIE
focus
Question stem: A nurse is planning care for four medical-
surgical patients. Which patient should the nurse assess first
during morning rounds?
,A. A patient with Type 2 diabetes scheduled for discharge today
who needs insulin teaching.
B. A post-op patient 2 hours post laparotomy with moderate
serosanguineous drainage on the dressing.
C. A patient with CHF reporting sudden weight gain of 0.5 kg
overnight.
D. A patient on telemetry who had one premature ventricular
contraction (PVC) overnight and is asymptomatic.
Correct answer: C
Rationales:
• Correct (C): Sudden weight gain suggests acute fluid
retention and possible decompensated heart failure—
requires immediate assessment and intervention.
• A (incorrect): Discharge teaching is important but not
time-sensitive compared to possible acute CHF
exacerbation.
• B (incorrect): Moderate serosanguineous drainage 2 hours
post-op is expected; persistent hemorrhage or large bright
red bleeding would be higher priority.
• D (incorrect): An isolated PVC in an asymptomatic patient
is lower priority than signs of acute fluid overload.
Teaching point: Prioritize patients showing signs of acute
physiologic instability.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Clinical Judgment
, 3
Reference: Ch. 1: Delegation & Collaboration — Scope of
Practice
Question stem: The RN delegates a stable postoperative
patient’s vital signs and pain score to a licensed practical nurse
(LPN). Which task must the RN retain and not delegate?
A. Instructing the LPN to record pain scores every 4 hours.
B. Performing the initial postoperative assessment including
neurovascular checks.
C. Requesting the LPN to administer PRN acetaminophen per
order.
D. Asking the LPN to report any abnormal findings immediately.
Correct answer: B
Rationales:
• Correct (B): Initial comprehensive assessments and the
identification of problems requiring independent nursing
judgment should be performed by the RN.
• A (incorrect): Recording pain scores is within LPN abilities
under RN delegation.
• C (incorrect): Medication administration per protocol may
be delegated depending on facility policy and LPN scope.
• D (incorrect): LPNs should report abnormalities—this is
appropriate delegation.
Teaching point: RNs retain initial comprehensive
