Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
1)
Reference: Ch. 1: Overview of Professional Nursing Concepts —
Quality & Safety (QSEN) competencies
Stem: A postoperative patient has decreased oxygen saturation
(SpO₂ 88%) and increasing confusion. As the nurse, which action
should be done first?
A. Call the surgeon to report the change.
B. Raise the head of the bed and apply supplemental oxygen.
C. Document the findings in the electronic record.
D. Notify respiratory therapy to perform an assessment.
Correct Answer: B
Rationale — Correct: Immediate physiologic deterioration
requires an independent nursing action to maintain
airway/oxygenation: raise head of bed and apply oxygen to
improve ventilation and perfusion before notifying others. This
follows patient safety and timely intervention principles in
,QSEN and clinical judgment.
Rationale — Incorrect A: Calling the surgeon delays immediate
oxygenation; notification is important but secondary to
stabilizing the patient.
Rationale — Incorrect C: Documentation is necessary but must
follow stabilization; it does not address the urgent hypoxemia.
Rationale — Incorrect D: Respiratory therapy may help, but
waiting for them delays the nurse’s immediate, independent
interventions.
Teaching Point: Prioritize immediate interventions that stabilize
airway and oxygenation.
Citation: Ignatavicius et al., 2024, Ch. 1: Overview of
Professional Nursing Concepts. Evolve
2)
Reference: Ch. 1: Clinical Judgment & Systems Thinking —
Recognizing patterns and prioritization
Stem: On morning assessment a nurse notes a patient’s blood
pressure trending from 130/76 to 88/50 over two hours with a
heart rate of 118 bpm and a cool, clammy skin. Which nursing
judgment is most appropriate?
A. Prepare for possible internal bleeding and notify the provider
immediately.
B. Encourage the patient to drink fluids to raise blood pressure.
C. Obtain the medication list and delay action until the provider
,arrives.
D. Reassess in one hour to confirm the trend.
Correct Answer: A
Rationale — Correct: Rapid hypotension with tachycardia and
cool diaphoresis suggests shock (possibly hemorrhagic).
Systems thinking and pattern recognition direct immediate
escalation and diagnostic/therapeutic interventions (notify
provider and prepare for bleeding workup).
Rationale — Incorrect B: Encouraging oral fluids is unsafe for an
unstable, hypotensive patient and may delay appropriate
treatment.
Rationale — Incorrect C: Reviewing meds is useful but should
not delay urgent assessment/treatment and notification.
Rationale — Incorrect D: Waiting an hour risks further
deterioration — immediate action is required.
Teaching Point: Use pattern recognition to escalate care
promptly for signs of shock.
Citation: Ignatavicius et al., 2024, Ch. 1: Clinical Judgment and
Systems Thinking. Evolve
3)
Reference: Ch. 1: Patient-Centered Care & Cultural Competence
Stem: A nurse provides discharge teaching to a 72-year-old
patient whose primary language is not English. The patient nods
, frequently but asks few questions. Which is the best nursing
action to ensure understanding?
A. Continue teaching using simple English and family gestures.
B. Use a professional medical interpreter and teach-back
method.
C. Give the written discharge summary and ask family to
interpret later.
D. Rely on the patient’s nodding as indicating comprehension.
Correct Answer: B
Rationale — Correct: Patient-centered care and cultural
competence require using professional interpreters and teach-
back to verify comprehension and ensure safe transitions. This
aligns with communication and safety standards.
Rationale — Incorrect A: Simplified speech without an
interpreter risks miscommunication; gestures can be
misleading.
Rationale — Incorrect C: Family interpretation may be
inaccurate and breaches privacy; written materials alone do not
confirm understanding.
Rationale — Incorrect D: Nodding is not a reliable indicator of
comprehension and can mask misunderstandings.
Teaching Point: Use professional interpreters and teach-back to
verify understanding.
Citation: Ignatavicius et al., 2024, Ch. 1: Patient-Centered Care.
Evolve
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
1)
Reference: Ch. 1: Overview of Professional Nursing Concepts —
Quality & Safety (QSEN) competencies
Stem: A postoperative patient has decreased oxygen saturation
(SpO₂ 88%) and increasing confusion. As the nurse, which action
should be done first?
A. Call the surgeon to report the change.
B. Raise the head of the bed and apply supplemental oxygen.
C. Document the findings in the electronic record.
D. Notify respiratory therapy to perform an assessment.
Correct Answer: B
Rationale — Correct: Immediate physiologic deterioration
requires an independent nursing action to maintain
airway/oxygenation: raise head of bed and apply oxygen to
improve ventilation and perfusion before notifying others. This
follows patient safety and timely intervention principles in
,QSEN and clinical judgment.
Rationale — Incorrect A: Calling the surgeon delays immediate
oxygenation; notification is important but secondary to
stabilizing the patient.
Rationale — Incorrect C: Documentation is necessary but must
follow stabilization; it does not address the urgent hypoxemia.
Rationale — Incorrect D: Respiratory therapy may help, but
waiting for them delays the nurse’s immediate, independent
interventions.
Teaching Point: Prioritize immediate interventions that stabilize
airway and oxygenation.
Citation: Ignatavicius et al., 2024, Ch. 1: Overview of
Professional Nursing Concepts. Evolve
2)
Reference: Ch. 1: Clinical Judgment & Systems Thinking —
Recognizing patterns and prioritization
Stem: On morning assessment a nurse notes a patient’s blood
pressure trending from 130/76 to 88/50 over two hours with a
heart rate of 118 bpm and a cool, clammy skin. Which nursing
judgment is most appropriate?
A. Prepare for possible internal bleeding and notify the provider
immediately.
B. Encourage the patient to drink fluids to raise blood pressure.
C. Obtain the medication list and delay action until the provider
,arrives.
D. Reassess in one hour to confirm the trend.
Correct Answer: A
Rationale — Correct: Rapid hypotension with tachycardia and
cool diaphoresis suggests shock (possibly hemorrhagic).
Systems thinking and pattern recognition direct immediate
escalation and diagnostic/therapeutic interventions (notify
provider and prepare for bleeding workup).
Rationale — Incorrect B: Encouraging oral fluids is unsafe for an
unstable, hypotensive patient and may delay appropriate
treatment.
Rationale — Incorrect C: Reviewing meds is useful but should
not delay urgent assessment/treatment and notification.
Rationale — Incorrect D: Waiting an hour risks further
deterioration — immediate action is required.
Teaching Point: Use pattern recognition to escalate care
promptly for signs of shock.
Citation: Ignatavicius et al., 2024, Ch. 1: Clinical Judgment and
Systems Thinking. Evolve
3)
Reference: Ch. 1: Patient-Centered Care & Cultural Competence
Stem: A nurse provides discharge teaching to a 72-year-old
patient whose primary language is not English. The patient nods
, frequently but asks few questions. Which is the best nursing
action to ensure understanding?
A. Continue teaching using simple English and family gestures.
B. Use a professional medical interpreter and teach-back
method.
C. Give the written discharge summary and ask family to
interpret later.
D. Rely on the patient’s nodding as indicating comprehension.
Correct Answer: B
Rationale — Correct: Patient-centered care and cultural
competence require using professional interpreters and teach-
back to verify comprehension and ensure safe transitions. This
aligns with communication and safety standards.
Rationale — Incorrect A: Simplified speech without an
interpreter risks miscommunication; gestures can be
misleading.
Rationale — Incorrect C: Family interpretation may be
inaccurate and breaches privacy; written materials alone do not
confirm understanding.
Rationale — Incorrect D: Nodding is not a reliable indicator of
comprehension and can mask misunderstandings.
Teaching Point: Use professional interpreters and teach-back to
verify understanding.
Citation: Ignatavicius et al., 2024, Ch. 1: Patient-Centered Care.
Evolve
