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. 2: Clinical Judgment: The Clinical Judgment
Model and Cue Processing
Question Stem: A postoperative patient on the medical-surgical
unit becomes increasingly restless and reports “I'm short of
breath.” Pulse ox 89% on room air, respiratory rate 28/min,
heart rate 110/min. Which action should the nurse take first?
A. Call the rapid response team.
B. Raise the head of the bed and apply supplemental oxygen.
C. Administer PRN opioid to reduce anxiety and promote rest.
D. Obtain an arterial blood gas (ABG) sample.
Correct Answer: B
Rationale — Correct: Raise head-of-bed and apply oxygen
immediately to improve oxygenation and reduce work of
breathing; this is the most time-sensitive, first-step intervention
,consistent with airway/oxygenation priorities. Clinical judgment
requires immediate stabilization while further data are
collected.
Rationale — A: Activating the rapid response may be
appropriate if the patient fails to stabilize, but immediate
interventions (oxygen, positioning) should not be delayed.
Rationale — C: Administering an opioid may worsen respiratory
status and is unsafe before assessing and optimizing
oxygenation.
Rationale — D: ABG provides diagnostic data but should not
delay immediate oxygenation efforts.
Teaching Point: Prioritize airway/oxygenation: position and
oxygen before diagnostic tests or sedatives.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 2:
Clinical Judgment and Cue Processing
2
Reference: Ch. 1: Professional Roles and Delegation in Medical-
Surgical Nursing
Question Stem: A nurse is delegating tasks to a licensed
practical nurse (LPN) and a nursing assistant (NA) for a stable
medical-surgical patient who requires routine wound irrigation,
oral care, and vitals every 4 hours. Which delegation is
appropriate?
,A. RN assigns wound irrigation to the NA, vitals to the LPN, and
oral care to the RN.
B. RN assigns wound irrigation to the LPN, vitals to the NA, and
oral care to the NA.
C. RN assigns wound irrigation to the RN, vitals to the LPN, and
oral care to the NA.
D. RN assigns wound irrigation to the LPN, vitals to the RN, and
oral care to the LPN.
Correct Answer: C
Rationale — Correct: LPNs may perform wound irrigation under
supervision; NAs can provide oral care and take vitals; the RN
retains responsibility for assessments and complex tasks. This
matches scope and supervision principles.
Rationale — A: NAs typically cannot perform wound irrigation;
RN-only assignment for oral care is unnecessary.
Rationale — B: Vitals may be done by NA, but assigning wound
irrigation to NA is outside NA scope.
Rationale — D: Having RN take vitals is inefficient; LPN can
perform wound irrigation but oral care may be delegated to NA.
Teaching Point: Delegate tasks based on scope, competence,
and patient complexity.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Delegation and Professional Roles
3
, Reference: Ch. 3: Concepts of Infection and Inflammation —
Asepsis & Transmission-Based Precautions
Question Stem: An immunocompromised patient on
neutropenic precautions develops a fever of 38.5°C (101.3°F).
Which nursing action best reflects evidence-based infection
prevention and early sepsis detection?
A. Begin broad-spectrum antibiotics immediately after
obtaining blood cultures.
B. Withhold antibiotics until the infectious disease consult
arrives.
C. Start acetaminophen and observe for 24 hours before
antibiotics.
D. Increase room isolation to airborne precautions.
Correct Answer: A
Rationale — Correct: In neutropenic fever, guidelines
recommend prompt blood cultures and immediate empiric
broad-spectrum antibiotics to reduce morbidity and mortality.
Early treatment takes priority.
Rationale — B: Waiting for consult delays time-sensitive
therapy and increases risk.
Rationale — C: Antipyretics alone are inadequate; fever in
neutropenia suggests possible bacteremia requiring antibiotics.
Rationale — D: Airborne precautions are for specific pathogens
(e.g., TB); neutropenic precautions emphasize protective
isolation for patient, not airborne changes.
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. 2: Clinical Judgment: The Clinical Judgment
Model and Cue Processing
Question Stem: A postoperative patient on the medical-surgical
unit becomes increasingly restless and reports “I'm short of
breath.” Pulse ox 89% on room air, respiratory rate 28/min,
heart rate 110/min. Which action should the nurse take first?
A. Call the rapid response team.
B. Raise the head of the bed and apply supplemental oxygen.
C. Administer PRN opioid to reduce anxiety and promote rest.
D. Obtain an arterial blood gas (ABG) sample.
Correct Answer: B
Rationale — Correct: Raise head-of-bed and apply oxygen
immediately to improve oxygenation and reduce work of
breathing; this is the most time-sensitive, first-step intervention
,consistent with airway/oxygenation priorities. Clinical judgment
requires immediate stabilization while further data are
collected.
Rationale — A: Activating the rapid response may be
appropriate if the patient fails to stabilize, but immediate
interventions (oxygen, positioning) should not be delayed.
Rationale — C: Administering an opioid may worsen respiratory
status and is unsafe before assessing and optimizing
oxygenation.
Rationale — D: ABG provides diagnostic data but should not
delay immediate oxygenation efforts.
Teaching Point: Prioritize airway/oxygenation: position and
oxygen before diagnostic tests or sedatives.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 2:
Clinical Judgment and Cue Processing
2
Reference: Ch. 1: Professional Roles and Delegation in Medical-
Surgical Nursing
Question Stem: A nurse is delegating tasks to a licensed
practical nurse (LPN) and a nursing assistant (NA) for a stable
medical-surgical patient who requires routine wound irrigation,
oral care, and vitals every 4 hours. Which delegation is
appropriate?
,A. RN assigns wound irrigation to the NA, vitals to the LPN, and
oral care to the RN.
B. RN assigns wound irrigation to the LPN, vitals to the NA, and
oral care to the NA.
C. RN assigns wound irrigation to the RN, vitals to the LPN, and
oral care to the NA.
D. RN assigns wound irrigation to the LPN, vitals to the RN, and
oral care to the LPN.
Correct Answer: C
Rationale — Correct: LPNs may perform wound irrigation under
supervision; NAs can provide oral care and take vitals; the RN
retains responsibility for assessments and complex tasks. This
matches scope and supervision principles.
Rationale — A: NAs typically cannot perform wound irrigation;
RN-only assignment for oral care is unnecessary.
Rationale — B: Vitals may be done by NA, but assigning wound
irrigation to NA is outside NA scope.
Rationale — D: Having RN take vitals is inefficient; LPN can
perform wound irrigation but oral care may be delegated to NA.
Teaching Point: Delegate tasks based on scope, competence,
and patient complexity.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Delegation and Professional Roles
3
, Reference: Ch. 3: Concepts of Infection and Inflammation —
Asepsis & Transmission-Based Precautions
Question Stem: An immunocompromised patient on
neutropenic precautions develops a fever of 38.5°C (101.3°F).
Which nursing action best reflects evidence-based infection
prevention and early sepsis detection?
A. Begin broad-spectrum antibiotics immediately after
obtaining blood cultures.
B. Withhold antibiotics until the infectious disease consult
arrives.
C. Start acetaminophen and observe for 24 hours before
antibiotics.
D. Increase room isolation to airborne precautions.
Correct Answer: A
Rationale — Correct: In neutropenic fever, guidelines
recommend prompt blood cultures and immediate empiric
broad-spectrum antibiotics to reduce morbidity and mortality.
Early treatment takes priority.
Rationale — B: Waiting for consult delays time-sensitive
therapy and increases risk.
Rationale — C: Antipyretics alone are inadequate; fever in
neutropenia suggests possible bacteremia requiring antibiotics.
Rationale — D: Airborne precautions are for specific pathogens
(e.g., TB); neutropenic precautions emphasize protective
isolation for patient, not airborne changes.
