Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
1
Reference: Ch. 1: Nursing Process & Clinical Judgment —
Assessment and Diagnosis
Question Stem: A 68-year-old patient postoperative from a
colectomy reports increasing abdominal pain and minimal
flatus. On assessment you note a distended abdomen and
hypoactive bowel sounds. What is the nurse’s priority action?
Options (A–D):
A. Administer prescribed opioid analgesic to relieve pain.
B. Notify the surgeon and prepare for possible imaging.
C. Offer a carbonated beverage to stimulate peristalsis.
D. Encourage ambulation and provide oral fluids as tolerated.
Correct Answer: B
Rationales:
• Correct (B): Distension with hypoactive sounds and
minimal flatus after abdominal surgery may indicate
, obstruction or ileus; notifying the surgeon and preparing
for imaging is a priority to evaluate for postoperative
complications. (Assessment → clinical judgment: escalate
for diagnostic evaluation.)
• A: Administering opioids could worsen ileus and mask
worsening signs; pain control is important but not the
immediate priority before evaluating complication risk.
• C: Carbonated beverages may increase gas but are
inappropriate when obstruction is possible and could
exacerbate issues.
• D: Ambulation is helpful for bowel recovery but is not the
immediate priority when signs suggest possible
obstruction; diagnostic clarification should precede routine
measures.
Teaching Point: Prioritize escalation and diagnostic evaluation
for postoperative abdominal distension with hypoactive sounds.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Nursing Process & Clinical Judgment
2
Reference: Ch. 1: Clinical Judgment — Recognizing Cues and
Prioritization
,Question Stem: During a morning assessment, which cue
indicates the highest risk for patient safety and requires
immediate action by the nurse?
Options (A–D):
A. A 79-year-old with new, intermittent confusion and a
temperature of 38.3°C.
B. A 54-year-old who reports pain 6/10 after knee surgery.
C. A 46-year-old ready for discharge with no home care
arranged.
D. A postoperative patient whose urinary catheter is draining 20
mL/hr.
Correct Answer: A
Rationales:
• Correct (A): New confusion plus fever in an older adult can
indicate delirium or sepsis — both high-risk conditions
needing immediate assessment and intervention.
• B: Moderate pain is important to treat but typically less
urgent than possible systemic infection or delirium.
• C: Discharge planning issue is important but not
immediately life-threatening; arrange social services.
• D: Low urine output (20 mL/hr) is concerning, but in the
context provided, new confusion with fever represents a
broader systemic risk requiring immediate action.
, Teaching Point: New delirium and fever in older adults demand
urgent assessment for infection or sepsis.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Clinical Judgment & Patient Safety
3
Reference: Ch. 1: Nursing Process — Planning & Outcome
Identification
Question Stem: A nurse is creating outcomes for a patient with
COPD hospitalized for an exacerbation. Which measurable
outcome reflects best practice and supports discharge
readiness?
Options (A–D):
A. Patient states understanding of COPD management.
B. Patient demonstrates correct inhaler technique using a
spacer with ≤2 errors.
C. Patient feels less short of breath at rest.
D. Patient plans to avoid environmental triggers.
Correct Answer: B
Rationales:
• Correct (B): A measurable, observable skill (inhaler
technique with ≤2 errors) aligns with outcome criteria and
predicts effective self-management and medication
delivery.
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
1
Reference: Ch. 1: Nursing Process & Clinical Judgment —
Assessment and Diagnosis
Question Stem: A 68-year-old patient postoperative from a
colectomy reports increasing abdominal pain and minimal
flatus. On assessment you note a distended abdomen and
hypoactive bowel sounds. What is the nurse’s priority action?
Options (A–D):
A. Administer prescribed opioid analgesic to relieve pain.
B. Notify the surgeon and prepare for possible imaging.
C. Offer a carbonated beverage to stimulate peristalsis.
D. Encourage ambulation and provide oral fluids as tolerated.
Correct Answer: B
Rationales:
• Correct (B): Distension with hypoactive sounds and
minimal flatus after abdominal surgery may indicate
, obstruction or ileus; notifying the surgeon and preparing
for imaging is a priority to evaluate for postoperative
complications. (Assessment → clinical judgment: escalate
for diagnostic evaluation.)
• A: Administering opioids could worsen ileus and mask
worsening signs; pain control is important but not the
immediate priority before evaluating complication risk.
• C: Carbonated beverages may increase gas but are
inappropriate when obstruction is possible and could
exacerbate issues.
• D: Ambulation is helpful for bowel recovery but is not the
immediate priority when signs suggest possible
obstruction; diagnostic clarification should precede routine
measures.
Teaching Point: Prioritize escalation and diagnostic evaluation
for postoperative abdominal distension with hypoactive sounds.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Nursing Process & Clinical Judgment
2
Reference: Ch. 1: Clinical Judgment — Recognizing Cues and
Prioritization
,Question Stem: During a morning assessment, which cue
indicates the highest risk for patient safety and requires
immediate action by the nurse?
Options (A–D):
A. A 79-year-old with new, intermittent confusion and a
temperature of 38.3°C.
B. A 54-year-old who reports pain 6/10 after knee surgery.
C. A 46-year-old ready for discharge with no home care
arranged.
D. A postoperative patient whose urinary catheter is draining 20
mL/hr.
Correct Answer: A
Rationales:
• Correct (A): New confusion plus fever in an older adult can
indicate delirium or sepsis — both high-risk conditions
needing immediate assessment and intervention.
• B: Moderate pain is important to treat but typically less
urgent than possible systemic infection or delirium.
• C: Discharge planning issue is important but not
immediately life-threatening; arrange social services.
• D: Low urine output (20 mL/hr) is concerning, but in the
context provided, new confusion with fever represents a
broader systemic risk requiring immediate action.
, Teaching Point: New delirium and fever in older adults demand
urgent assessment for infection or sepsis.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Clinical Judgment & Patient Safety
3
Reference: Ch. 1: Nursing Process — Planning & Outcome
Identification
Question Stem: A nurse is creating outcomes for a patient with
COPD hospitalized for an exacerbation. Which measurable
outcome reflects best practice and supports discharge
readiness?
Options (A–D):
A. Patient states understanding of COPD management.
B. Patient demonstrates correct inhaler technique using a
spacer with ≤2 errors.
C. Patient feels less short of breath at rest.
D. Patient plans to avoid environmental triggers.
Correct Answer: B
Rationales:
• Correct (B): A measurable, observable skill (inhaler
technique with ≤2 errors) aligns with outcome criteria and
predicts effective self-management and medication
delivery.
