Medical-Surgical Nursing: Concepts for Interprofessional
Collaborative Care (11th Ed.) — Unit I (Ch. 1–9).
Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
Reference: Ch. 1: Overview of Professional Nursing Concepts —
Scope, Roles, and Standards
Question stem: A newly hired med-surg RN is assigning tasks
for a stable postoperative patient who requires routine oral
medications, ambulation assistance, and a wound dressing
change. Which assignment demonstrates correct delegation
and protects patient safety?
A. RN assigns oral medications to nursing assistant, dressing
change to LPN, and supervises ambulation.
B. RN performs medication administration, delegates
ambulation to nursing assistant, and assigns dressing change to
LPN.
C. RN delegates medication administration to LPN, dressing
change to nursing assistant, and ambulation to LPN.
,D. RN delegates all tasks to nursing assistant with instructions to
call if concerns arise.
Correct answer: B
Rationale (correct): The RN retains responsibility for medication
administration when delegation would exceed the assistant’s
scope; delegating ambulation to a nursing assistant and
dressing change to an LPN matches typical scopes and
preserves safety while maintaining RN accountability.
Rationale (A): Nursing assistants generally cannot administer
oral medications, so this would be unsafe.
Rationale (C): Dressing changes often require LPN skill
depending on complexity; giving dressing changes to a nursing
assistant is inappropriate.
Rationale (D): Delegating all tasks to an assistant without
appropriate skill or supervision violates scope and risks patient
harm.
Teaching point: Delegate tasks based on scope, competency,
and patient stability.
Citation: Ignatavicius et al., 2024, Ch. 1: Professional Roles and
Delegation
2
Reference: Ch. 2: Clinical Judgment and Systems Thinking —
Clinical Judgment Measurement Model (CJMM)
,Question stem: A patient with COPD reports increased dyspnea
and increased sputum that is yellow-green. The RN notes
respiratory rate 28, SpO₂ 88% on room air, and coarse crackles
in the lower lobes. Which nursing action should the RN
implement first?
A. Administer prescribed albuterol nebulizer treatment and
reassess respiratory status.
B. Obtain sputum culture and start broad-spectrum antibiotics
per protocol.
C. Encourage deep breathing and incentive spirometry every
hour.
D. Elevate the head of the bed, apply supplemental oxygen, and
reassess SpO₂.
Correct answer: D
Rationale (correct): Using clinical judgment, airway and
oxygenation take priority; elevating the head, giving
supplemental oxygen, and reassessing address immediate
hypoxemia (SpO₂ 88%) before other interventions.
Rationale (A): Bronchodilator is appropriate but oxygenation
must be stabilized first.
Rationale (B): Cultures and antibiotics may be indicated, but are
not first actions for acute hypoxemia.
Rationale (C): Incentive spirometry is useful but inadequate
alone for current hypoxemia.
Teaching point: Prioritize airway/oxygenation before secondary
treatments.
, Citation: Ignatavicius et al., 2024, Ch. 2: Clinical Judgment and
Prioritization
3
Reference: Ch. 3: Overview of Health Concepts — Inflammation
and Infection
Question stem: A patient with a stage II pressure injury shows
increasing localized redness, warmth, and purulent drainage.
Vital signs: T 38.3°C, HR 102, WBC 13,500. Which interpretation
best reflects the patient’s condition?
A. Localized inflammation only — normal healing response.
B. Superficial colonization — no systemic response; use topical
antiseptic only.
C. Local infection with systemic inflammatory response — begin
systemic antibiotics per provider.
D. Allergic reaction to dressing — change dressing type and
monitor.
Correct answer: C
Rationale (correct): The signs (purulent drainage, fever,
leukocytosis, tachycardia) indicate local infection with systemic
response, warranting systemic antibiotic therapy and wound
management.
Rationale (A): Purulence and systemic signs are beyond normal
inflammation.
Rationale (B): Colonization does not cause fever or
Collaborative Care (11th Ed.) — Unit I (Ch. 1–9).
Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
Reference: Ch. 1: Overview of Professional Nursing Concepts —
Scope, Roles, and Standards
Question stem: A newly hired med-surg RN is assigning tasks
for a stable postoperative patient who requires routine oral
medications, ambulation assistance, and a wound dressing
change. Which assignment demonstrates correct delegation
and protects patient safety?
A. RN assigns oral medications to nursing assistant, dressing
change to LPN, and supervises ambulation.
B. RN performs medication administration, delegates
ambulation to nursing assistant, and assigns dressing change to
LPN.
C. RN delegates medication administration to LPN, dressing
change to nursing assistant, and ambulation to LPN.
,D. RN delegates all tasks to nursing assistant with instructions to
call if concerns arise.
Correct answer: B
Rationale (correct): The RN retains responsibility for medication
administration when delegation would exceed the assistant’s
scope; delegating ambulation to a nursing assistant and
dressing change to an LPN matches typical scopes and
preserves safety while maintaining RN accountability.
Rationale (A): Nursing assistants generally cannot administer
oral medications, so this would be unsafe.
Rationale (C): Dressing changes often require LPN skill
depending on complexity; giving dressing changes to a nursing
assistant is inappropriate.
Rationale (D): Delegating all tasks to an assistant without
appropriate skill or supervision violates scope and risks patient
harm.
Teaching point: Delegate tasks based on scope, competency,
and patient stability.
Citation: Ignatavicius et al., 2024, Ch. 1: Professional Roles and
Delegation
2
Reference: Ch. 2: Clinical Judgment and Systems Thinking —
Clinical Judgment Measurement Model (CJMM)
,Question stem: A patient with COPD reports increased dyspnea
and increased sputum that is yellow-green. The RN notes
respiratory rate 28, SpO₂ 88% on room air, and coarse crackles
in the lower lobes. Which nursing action should the RN
implement first?
A. Administer prescribed albuterol nebulizer treatment and
reassess respiratory status.
B. Obtain sputum culture and start broad-spectrum antibiotics
per protocol.
C. Encourage deep breathing and incentive spirometry every
hour.
D. Elevate the head of the bed, apply supplemental oxygen, and
reassess SpO₂.
Correct answer: D
Rationale (correct): Using clinical judgment, airway and
oxygenation take priority; elevating the head, giving
supplemental oxygen, and reassessing address immediate
hypoxemia (SpO₂ 88%) before other interventions.
Rationale (A): Bronchodilator is appropriate but oxygenation
must be stabilized first.
Rationale (B): Cultures and antibiotics may be indicated, but are
not first actions for acute hypoxemia.
Rationale (C): Incentive spirometry is useful but inadequate
alone for current hypoxemia.
Teaching point: Prioritize airway/oxygenation before secondary
treatments.
, Citation: Ignatavicius et al., 2024, Ch. 2: Clinical Judgment and
Prioritization
3
Reference: Ch. 3: Overview of Health Concepts — Inflammation
and Infection
Question stem: A patient with a stage II pressure injury shows
increasing localized redness, warmth, and purulent drainage.
Vital signs: T 38.3°C, HR 102, WBC 13,500. Which interpretation
best reflects the patient’s condition?
A. Localized inflammation only — normal healing response.
B. Superficial colonization — no systemic response; use topical
antiseptic only.
C. Local infection with systemic inflammatory response — begin
systemic antibiotics per provider.
D. Allergic reaction to dressing — change dressing type and
monitor.
Correct answer: C
Rationale (correct): The signs (purulent drainage, fever,
leukocytosis, tachycardia) indicate local infection with systemic
response, warranting systemic antibiotic therapy and wound
management.
Rationale (A): Purulence and systemic signs are beyond normal
inflammation.
Rationale (B): Colonization does not cause fever or
