Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
Item 1
Reference: Ch. 1 — Clinical Judgment & Nursing Process
(Overview)
Stem: A 68-year-old post-op patient has new onset confusion
and a respiratory rate of 8 breaths/min. Which nursing action
should the RN perform first?
A. Reorient the patient and provide a clock and calendar.
B. Perform a focused respiratory assessment and administer
oxygen as needed.
C. Notify the surgeon about a change in mental status.
D. Obtain a full set of vital signs and place the patient on fall
precautions.
Correct Answer: B
Rationales:
• B (Correct): A respiratory rate of 8 indicates
hypoventilation which may cause hypoxia and altered
, mental status; immediate respiratory assessment and
oxygenation are highest priority for patient safety.
(Application of airway/breathing priority and clinical
judgment.)
• A: Reorientation addresses delirium but does not treat
potential hypoxia causing confusion.
• C: Notifying the surgeon is important but comes after
immediate stabilization of airway/breathing.
• D: Obtaining vitals and fall precautions are appropriate but
secondary to addressing low respiratory rate.
Teaching Point: Always address airway/breathing before
orientation or notification.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Clinical Judgment & Nursing Process
Item 2
Reference: Ch. 1 — Prioritization & Safety
Stem: During shift report, an RN receives assignment: (1) stable
postop patient needing discharge teaching, (2) one patient with
chest pain on telemetry, (3) a patient requesting pain
medication for severe abdominal pain, and (4) a patient
scheduled for an MRI in 30 minutes. Which patient should the
RN assess first?
A. The patient needing discharge teaching.
,B. The patient with chest pain on telemetry.
C. The patient requesting pain medication.
D. The patient scheduled for MRI.
Correct Answer: B
Rationales:
• B (Correct): Chest pain on telemetry suggests potential
acute coronary event — immediate assessment and
prioritization are required to prevent deterioration.
• A: Discharge teaching is important but nonurgent
compared with potential ischemia.
• C: Severe pain requires timely assessment but chest pain
with possible cardiac etiology takes precedence.
• D: MRI scheduling is logistical and lower priority than an
acute symptom.
Teaching Point: Prioritize unstable or potentially life-
threatening problems first.
Citation: Ignatavicius et al., 2024, Ch. 1: Prioritization & Safety
Item 3
Reference: Ch. 1 — Delegation & Scope of Practice
Stem: An RN is delegating tasks to a licensed practical nurse
(LPN) and an unlicensed assistive personnel (UAP). Which task is
appropriate to delegate to the UAP?
, A. Administer oral analgesic as prescribed.
B. Assist the patient with ambulation to the bathroom.
C. Teach the patient about the signs of wound infection.
D. Complete a focused assessment of incision site and report
findings.
Correct Answer: B
Rationales:
• B (Correct): Ambulation assistance is within the UAP’s
scope when the patient is stable; it’s a safe, routine activity
that does not require clinical judgment.
• A: Medication administration requires licensed personnel.
• C: Patient education involves clinical judgment and should
be done by licensed staff.
• D: Focused assessment and interpretation of wound
findings require clinical judgment and licensure.
Teaching Point: Delegate routine, stable-care tasks to UAP;
reserve assessment/teaching for licensed nurses.
Citation: Ignatavicius et al., 2024, Ch. 1: Delegation & Scope of
Practice
Item 4
Reference: Ch. 1 — Interprofessional Collaboration
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
Item 1
Reference: Ch. 1 — Clinical Judgment & Nursing Process
(Overview)
Stem: A 68-year-old post-op patient has new onset confusion
and a respiratory rate of 8 breaths/min. Which nursing action
should the RN perform first?
A. Reorient the patient and provide a clock and calendar.
B. Perform a focused respiratory assessment and administer
oxygen as needed.
C. Notify the surgeon about a change in mental status.
D. Obtain a full set of vital signs and place the patient on fall
precautions.
Correct Answer: B
Rationales:
• B (Correct): A respiratory rate of 8 indicates
hypoventilation which may cause hypoxia and altered
, mental status; immediate respiratory assessment and
oxygenation are highest priority for patient safety.
(Application of airway/breathing priority and clinical
judgment.)
• A: Reorientation addresses delirium but does not treat
potential hypoxia causing confusion.
• C: Notifying the surgeon is important but comes after
immediate stabilization of airway/breathing.
• D: Obtaining vitals and fall precautions are appropriate but
secondary to addressing low respiratory rate.
Teaching Point: Always address airway/breathing before
orientation or notification.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Clinical Judgment & Nursing Process
Item 2
Reference: Ch. 1 — Prioritization & Safety
Stem: During shift report, an RN receives assignment: (1) stable
postop patient needing discharge teaching, (2) one patient with
chest pain on telemetry, (3) a patient requesting pain
medication for severe abdominal pain, and (4) a patient
scheduled for an MRI in 30 minutes. Which patient should the
RN assess first?
A. The patient needing discharge teaching.
,B. The patient with chest pain on telemetry.
C. The patient requesting pain medication.
D. The patient scheduled for MRI.
Correct Answer: B
Rationales:
• B (Correct): Chest pain on telemetry suggests potential
acute coronary event — immediate assessment and
prioritization are required to prevent deterioration.
• A: Discharge teaching is important but nonurgent
compared with potential ischemia.
• C: Severe pain requires timely assessment but chest pain
with possible cardiac etiology takes precedence.
• D: MRI scheduling is logistical and lower priority than an
acute symptom.
Teaching Point: Prioritize unstable or potentially life-
threatening problems first.
Citation: Ignatavicius et al., 2024, Ch. 1: Prioritization & Safety
Item 3
Reference: Ch. 1 — Delegation & Scope of Practice
Stem: An RN is delegating tasks to a licensed practical nurse
(LPN) and an unlicensed assistive personnel (UAP). Which task is
appropriate to delegate to the UAP?
, A. Administer oral analgesic as prescribed.
B. Assist the patient with ambulation to the bathroom.
C. Teach the patient about the signs of wound infection.
D. Complete a focused assessment of incision site and report
findings.
Correct Answer: B
Rationales:
• B (Correct): Ambulation assistance is within the UAP’s
scope when the patient is stable; it’s a safe, routine activity
that does not require clinical judgment.
• A: Medication administration requires licensed personnel.
• C: Patient education involves clinical judgment and should
be done by licensed staff.
• D: Focused assessment and interpretation of wound
findings require clinical judgment and licensure.
Teaching Point: Delegate routine, stable-care tasks to UAP;
reserve assessment/teaching for licensed nurses.
Citation: Ignatavicius et al., 2024, Ch. 1: Delegation & Scope of
Practice
Item 4
Reference: Ch. 1 — Interprofessional Collaboration
