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 for
Medical-Surgical Nursing — Scope of practice and delegation
Question Stem: A charge nurse must assign four patients to an
RN and an LPN on a med-surg unit. Which assignment best
demonstrates appropriate delegation while ensuring patient
safety?
A. LPN — newly admitted post-op patient with PRN pain needs;
RN — stable diabetic patient needing insulin teaching
B. LPN — stable hepatic cirrhosis patient with routine dressing
changes; RN — new stroke admission requiring neurologic
assessment and teaching
C. LPN — unstable GI bleed requiring frequent vitals and
titration of infusion; RN — routine IV site checks for stable
patient
D. LPN — patient requiring initial admission assessment and
discharge teaching; RN — patient scheduled for routine med
administration only
,Correct Answer: B
Rationales:
• Correct (B): LPNs may perform routine care (dressings) for
stable patients; RNs should handle new admissions and
focused neurologic assessments requiring clinical
judgment and teaching. This matches delegation guidelines
for skill level and safety.
• A: Incorrect — LPNs can give meds and monitor, but a
newly admitted post-op patient may need initial RN
assessment and teaching.
• C: Incorrect — Unstable patients and titration require RN
clinical judgment; unsafe to delegate to LPN.
• D: Incorrect — Initial admission assessment and discharge
teaching require RN scope; assigning only routine
medication to RN is an inappropriate mismatch.
Teaching Point: Delegate tasks based on scope, stability,
and assessment/teaching needs.
Citation: Ignatavicius et al., 2024, Ch. 1: Professional Roles
and Delegation
2 (Foundational Knowledge)
Reference: Ch. 2: Clinical Judgment and Systems Thinking —
Clinical Judgment Measurement Model (CJMM)
Question Stem: Which step of the nursing process most directly
aligns with the "interpretation" phase of the Clinical Judgment
,Measurement Model?
A. Implementation
B. Assessment
C. Planning
D. Evaluation
Correct Answer: B
Rationales:
• Correct (B): Interpretation uses collected data to identify
problems — paralleling Assessment where data are
gathered and interpreted.
• A: Incorrect — Implementation is action based on
decisions, not initial data interpretation.
• C: Incorrect — Planning is formulating interventions after
interpretation, not the interpretation itself.
• D: Incorrect — Evaluation judges outcomes; interpretation
precedes planning and implementation.
Teaching Point: Interpretation of data occurs during
assessment, informing subsequent decisions.
Citation: Ignatavicius et al., 2024, Ch. 2: Clinical Judgment
and the CJMM
3
Reference: Ch. 2: Clinical Judgment and Systems Thinking —
Prioritization & recognition of cues
Question Stem: A patient with COPD reports increased
, dyspnea, has SpO₂ 88% on 2 L NC, and new confusion. Which
action should the nurse take first?
A. Increase oxygen to 4 L via nasal cannula.
B. Assist the patient into high-Fowler’s position and recheck
SpO₂.
C. Call the respiratory therapist for immediate nebulized
bronchodilator.
D. Obtain an arterial blood gas (ABG).
Correct Answer: B
Rationales:
• Correct (B): Positioning improves ventilation promptly and
is an immediate, low-risk action to relieve hypoxia and
should precede other interventions.
• A: Incorrect — Rapidly increasing oxygen without
reassessment may be needed, but first repositioning and
reassessment are immediate and safer.
• C: Incorrect — RT involvement is important, but first basic
nursing interventions and reassessment should occur now.
• D: Incorrect — ABG gives diagnostic data but is not the
priority action when immediate hypoxia is present.
Teaching Point: Perform immediate, low-risk respiratory
interventions and reassess before escalating.
Citation: Ignatavicius et al., 2024, Ch. 2: Prioritization and
Cue Recognition
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 for
Medical-Surgical Nursing — Scope of practice and delegation
Question Stem: A charge nurse must assign four patients to an
RN and an LPN on a med-surg unit. Which assignment best
demonstrates appropriate delegation while ensuring patient
safety?
A. LPN — newly admitted post-op patient with PRN pain needs;
RN — stable diabetic patient needing insulin teaching
B. LPN — stable hepatic cirrhosis patient with routine dressing
changes; RN — new stroke admission requiring neurologic
assessment and teaching
C. LPN — unstable GI bleed requiring frequent vitals and
titration of infusion; RN — routine IV site checks for stable
patient
D. LPN — patient requiring initial admission assessment and
discharge teaching; RN — patient scheduled for routine med
administration only
,Correct Answer: B
Rationales:
• Correct (B): LPNs may perform routine care (dressings) for
stable patients; RNs should handle new admissions and
focused neurologic assessments requiring clinical
judgment and teaching. This matches delegation guidelines
for skill level and safety.
• A: Incorrect — LPNs can give meds and monitor, but a
newly admitted post-op patient may need initial RN
assessment and teaching.
• C: Incorrect — Unstable patients and titration require RN
clinical judgment; unsafe to delegate to LPN.
• D: Incorrect — Initial admission assessment and discharge
teaching require RN scope; assigning only routine
medication to RN is an inappropriate mismatch.
Teaching Point: Delegate tasks based on scope, stability,
and assessment/teaching needs.
Citation: Ignatavicius et al., 2024, Ch. 1: Professional Roles
and Delegation
2 (Foundational Knowledge)
Reference: Ch. 2: Clinical Judgment and Systems Thinking —
Clinical Judgment Measurement Model (CJMM)
Question Stem: Which step of the nursing process most directly
aligns with the "interpretation" phase of the Clinical Judgment
,Measurement Model?
A. Implementation
B. Assessment
C. Planning
D. Evaluation
Correct Answer: B
Rationales:
• Correct (B): Interpretation uses collected data to identify
problems — paralleling Assessment where data are
gathered and interpreted.
• A: Incorrect — Implementation is action based on
decisions, not initial data interpretation.
• C: Incorrect — Planning is formulating interventions after
interpretation, not the interpretation itself.
• D: Incorrect — Evaluation judges outcomes; interpretation
precedes planning and implementation.
Teaching Point: Interpretation of data occurs during
assessment, informing subsequent decisions.
Citation: Ignatavicius et al., 2024, Ch. 2: Clinical Judgment
and the CJMM
3
Reference: Ch. 2: Clinical Judgment and Systems Thinking —
Prioritization & recognition of cues
Question Stem: A patient with COPD reports increased
, dyspnea, has SpO₂ 88% on 2 L NC, and new confusion. Which
action should the nurse take first?
A. Increase oxygen to 4 L via nasal cannula.
B. Assist the patient into high-Fowler’s position and recheck
SpO₂.
C. Call the respiratory therapist for immediate nebulized
bronchodilator.
D. Obtain an arterial blood gas (ABG).
Correct Answer: B
Rationales:
• Correct (B): Positioning improves ventilation promptly and
is an immediate, low-risk action to relieve hypoxia and
should precede other interventions.
• A: Incorrect — Rapidly increasing oxygen without
reassessment may be needed, but first repositioning and
reassessment are immediate and safer.
• C: Incorrect — RT involvement is important, but first basic
nursing interventions and reassessment should occur now.
• D: Incorrect — ABG gives diagnostic data but is not the
priority action when immediate hypoxia is present.
Teaching Point: Perform immediate, low-risk respiratory
interventions and reassess before escalating.
Citation: Ignatavicius et al., 2024, Ch. 2: Prioritization and
Cue Recognition
