Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
Q1
Reference: Ch. 1: Overview of Professional Nursing Concepts —
Patient-Centered Care / Safety
Question Stem: A 68-year-old post-op patient requests
assistance to the bathroom 2 hours after abdominal surgery.
Vital signs are stable, but the patient reports dizziness when
standing. Which action should the nurse take first?
A. Assist the patient to the bathroom using a standard gait belt
and a single nurse.
B. Measure orthostatic vital signs and ask about
lightheadedness before ambulation.
C. Encourage the patient to try standing and walk slowly to the
bathroom.
D. Offer a bedside urinal and delay ambulation until the next
scheduled rounding.
Correct Answer: B
Rationale — Correct: Measuring orthostatic vitals and asking
,about lightheadedness applies the assessment phase of the
nursing process and identifies instability before ambulation,
reducing fall risk.
Rationale — Incorrect:
A. A standard gait belt and one nurse may be inadequate if
orthostatic hypotension exists — assessment first.
C. Encouraging unsupported standing risks syncope or falls
without prior assessment.
D. Offering a urinal delays necessary ambulation without
assessing safety and may increase complications from
immobility.
Teaching Point: Always assess for orthostatic changes and
dizziness before ambulation to prevent falls.
Citation: Ignatavicius et al., 2024, Ch. 1: Overview of
Professional Nursing Concepts for Medical-Surgical Nursing.
Elsevier Shop
Q2
Reference: Ch. 1: Overview — Clinical Judgment & Systems
Thinking
Question Stem: During handoff, the outgoing nurse states, “Mr.
L has a new O2 requirement of 4 L via nasal cannula for SpO₂
88% on room air.” The oncoming nurse’s first action is to:
A. Document the information and begin the scheduled
medication administration.
B. Place the patient on 4 L NC immediately without assessing.
,C. Go directly to the patient, verify SpO₂, respiratory effort, and
current oxygen delivery.
D. Call respiratory therapy to evaluate before visiting the
patient.
Correct Answer: C
Rationale — Correct: Verifying the patient’s current status
(assessment) is the first step in clinical judgment—confirming
SpO₂ and respiratory effort guides immediate interventions.
Rationale — Incorrect:
A. Waiting to document and continue tasks delays urgent
assessment for hypoxemia.
B. Applying 4 L without confirming need may mask
deterioration or miss alternative causes.
D. Calling respiratory therapy before assessment delays
immediate bedside evaluation and nursing judgment.
Teaching Point: Handoff information prompts immediate
bedside verification to guide safe, timely care.
Citation: Ignatavicius et al., 2024, Ch. 1: Clinical judgment and
systems thinking. Evolve
Q3
Reference: Ch. 1: Overview — Teamwork & Interprofessional
Collaboration
Question Stem: A nurse recognizes that a postop patient’s Foley
bag is full and the patient looks uncomfortable, but the nurse’s
workload is heavy. Which delegation is appropriate to a licensed
, practical nurse (LPN)/licensed vocational nurse (LVN)?
A. Ask the LPN to assess the bladder for distention and remove
the catheter.
B. Ask the LPN to empty the Foley bag, measure output, and
report findings.
C. Ask the LPN to interpret complex urinalysis results and adjust
IV fluids.
D. Ask the LPN to independently discontinue the Foley and
order bladder scan.
Correct Answer: B
Rationale — Correct: Emptying and measuring urinary output
are within typical LPN scope under RN supervision; the RN
maintains accountability for assessment and complex decisions.
Rationale — Incorrect:
A. Assessing bladder distention and removing catheters may
require RN clinical judgment and physician orders.
C. Interpreting complex labs and adjusting IV fluids are RN or
provider responsibilities.
D. Discontinuing catheters and ordering diagnostic tests are
outside typical LPN independent scope.
Teaching Point: Delegate tasks matching the team member’s
scope while retaining overall accountability.
Citation: Ignatavicius et al., 2024, Ch. 1: Teamwork and
interprofessional collaboration. Elsevier Shop
Q4
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
Q1
Reference: Ch. 1: Overview of Professional Nursing Concepts —
Patient-Centered Care / Safety
Question Stem: A 68-year-old post-op patient requests
assistance to the bathroom 2 hours after abdominal surgery.
Vital signs are stable, but the patient reports dizziness when
standing. Which action should the nurse take first?
A. Assist the patient to the bathroom using a standard gait belt
and a single nurse.
B. Measure orthostatic vital signs and ask about
lightheadedness before ambulation.
C. Encourage the patient to try standing and walk slowly to the
bathroom.
D. Offer a bedside urinal and delay ambulation until the next
scheduled rounding.
Correct Answer: B
Rationale — Correct: Measuring orthostatic vitals and asking
,about lightheadedness applies the assessment phase of the
nursing process and identifies instability before ambulation,
reducing fall risk.
Rationale — Incorrect:
A. A standard gait belt and one nurse may be inadequate if
orthostatic hypotension exists — assessment first.
C. Encouraging unsupported standing risks syncope or falls
without prior assessment.
D. Offering a urinal delays necessary ambulation without
assessing safety and may increase complications from
immobility.
Teaching Point: Always assess for orthostatic changes and
dizziness before ambulation to prevent falls.
Citation: Ignatavicius et al., 2024, Ch. 1: Overview of
Professional Nursing Concepts for Medical-Surgical Nursing.
Elsevier Shop
Q2
Reference: Ch. 1: Overview — Clinical Judgment & Systems
Thinking
Question Stem: During handoff, the outgoing nurse states, “Mr.
L has a new O2 requirement of 4 L via nasal cannula for SpO₂
88% on room air.” The oncoming nurse’s first action is to:
A. Document the information and begin the scheduled
medication administration.
B. Place the patient on 4 L NC immediately without assessing.
,C. Go directly to the patient, verify SpO₂, respiratory effort, and
current oxygen delivery.
D. Call respiratory therapy to evaluate before visiting the
patient.
Correct Answer: C
Rationale — Correct: Verifying the patient’s current status
(assessment) is the first step in clinical judgment—confirming
SpO₂ and respiratory effort guides immediate interventions.
Rationale — Incorrect:
A. Waiting to document and continue tasks delays urgent
assessment for hypoxemia.
B. Applying 4 L without confirming need may mask
deterioration or miss alternative causes.
D. Calling respiratory therapy before assessment delays
immediate bedside evaluation and nursing judgment.
Teaching Point: Handoff information prompts immediate
bedside verification to guide safe, timely care.
Citation: Ignatavicius et al., 2024, Ch. 1: Clinical judgment and
systems thinking. Evolve
Q3
Reference: Ch. 1: Overview — Teamwork & Interprofessional
Collaboration
Question Stem: A nurse recognizes that a postop patient’s Foley
bag is full and the patient looks uncomfortable, but the nurse’s
workload is heavy. Which delegation is appropriate to a licensed
, practical nurse (LPN)/licensed vocational nurse (LVN)?
A. Ask the LPN to assess the bladder for distention and remove
the catheter.
B. Ask the LPN to empty the Foley bag, measure output, and
report findings.
C. Ask the LPN to interpret complex urinalysis results and adjust
IV fluids.
D. Ask the LPN to independently discontinue the Foley and
order bladder scan.
Correct Answer: B
Rationale — Correct: Emptying and measuring urinary output
are within typical LPN scope under RN supervision; the RN
maintains accountability for assessment and complex decisions.
Rationale — Incorrect:
A. Assessing bladder distention and removing catheters may
require RN clinical judgment and physician orders.
C. Interpreting complex labs and adjusting IV fluids are RN or
provider responsibilities.
D. Discontinuing catheters and ordering diagnostic tests are
outside typical LPN independent scope.
Teaching Point: Delegate tasks matching the team member’s
scope while retaining overall accountability.
Citation: Ignatavicius et al., 2024, Ch. 1: Teamwork and
interprofessional collaboration. Elsevier Shop
Q4
