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
1
Reference: Ch. 1: Professional Nursing Concepts — Roles,
Accountability, and Scope of Practice
Question Stem: A newly licensed RN on a medical-surgical
unit is assigned an unstable postoperative patient and a
stable patient awaiting discharge teaching. Which
assignment action demonstrates the best professional
judgment?
A. Accept both patients and provide discharge teaching
first.
B. Request the stable patient be reassigned so the RN can
focus on the unstable patient.
C. Accept both patients, perform an immediate assessment
of the postoperative patient, and delegate discharge
teaching to a trained UAP.
D. Decline the assignment because it exceeds the safe RN
workload.
,Correct Answer: C
Rationale — Correct: The RN should prioritize immediate
assessment of the unstable postoperative patient
(safety/initial assessment) and use appropriate delegation
for routine tasks (discharge teaching can be delegated
when UAP is trained), reflecting accountability and
delegation within scope.
Rationale — Incorrect:
A. Providing discharge teaching first ignores prioritization
of the unstable patient and risks harm.
B. Requesting reassignment may be appropriate in some
circumstances but immediate patient assessment and
delegation are more practical and timely.
D. Declining outright without attempting prioritization or
delegation fails to use clinical judgment and
interprofessional resources.
Teaching Point: Prioritize unstable patients; use delegation
appropriately to maintain safety.
Citation: Ignatavicius et al., 2024, Ch. 1: Roles and
Accountability
2
Reference: Ch. 2: Clinical Judgment and Systems Thinking
— Tanner’s Model and Decision Making
Question Stem: A patient with chronic heart failure reports
gradual weight gain and increased shortness of breath over
,48 hours. Following Tanner’s clinical judgment model, what
is the nurse’s next best action after noticing these data?
A. Document findings and reassess in 8 hours.
B. Call the provider to report possible fluid overload and
request diuretic order.
C. Increase the patient’s oral fluid intake to relieve thirst
from dry mouth.
D. Notify the dietitian to restrict sodium further.
Correct Answer: B
Rationale — Correct: Noticing worsening signs (weight
gain, dyspnea) suggests fluid overload; the nurse should
interpret and respond by communicating promptly to
obtain an order for treatment (e.g., diuretic), aligning with
clinical judgment and timely intervention.
Rationale — Incorrect:
A. Waiting delays necessary treatment and risks
deterioration.
C. Increasing fluids worsens volume overload in heart
failure.
D. Sodium restriction is a long-term plan and does not
address acute fluid accumulation.
Teaching Point: Recognize early decompensation and
communicate for immediate treatment.
Citation: Ignatavicius et al., 2024, Ch. 2: Tanner’s Model
and Clinical Decision Making
, 3
Reference: Ch. 3: Health Concepts — Mobility, Tissue
Integrity, and Risk Assessment
Question Stem: During morning rounds a nurse identifies a
previously mobile patient now complaining of new calf
pain and unilateral leg swelling. What action should the
nurse take first?
A. Apply warm compresses to the swollen calf and
ambulate the patient.
B. Measure calf circumferences, elevate the limb, and
notify the provider for suspected DVT.
C. Encourage the patient to perform ankle pumps and
continue routine care.
D. Administer PRN analgesic and document findings.
Correct Answer: B
Rationale — Correct: New unilateral swelling and calf pain
raise concern for deep vein thrombosis; immediate
measurement, limb elevation, and provider notification for
diagnostic testing and anticoagulation decisions is priority
to prevent embolism.
Rationale — Incorrect:
A. Ambulation and warm compresses before evaluation
could dislodge a thrombus.
C. Encouraging activity without assessment risks harm if
DVT present.
D. Analgesia alone treats symptom but fails to address
potentially life-threatening cause.
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
1
Reference: Ch. 1: Professional Nursing Concepts — Roles,
Accountability, and Scope of Practice
Question Stem: A newly licensed RN on a medical-surgical
unit is assigned an unstable postoperative patient and a
stable patient awaiting discharge teaching. Which
assignment action demonstrates the best professional
judgment?
A. Accept both patients and provide discharge teaching
first.
B. Request the stable patient be reassigned so the RN can
focus on the unstable patient.
C. Accept both patients, perform an immediate assessment
of the postoperative patient, and delegate discharge
teaching to a trained UAP.
D. Decline the assignment because it exceeds the safe RN
workload.
,Correct Answer: C
Rationale — Correct: The RN should prioritize immediate
assessment of the unstable postoperative patient
(safety/initial assessment) and use appropriate delegation
for routine tasks (discharge teaching can be delegated
when UAP is trained), reflecting accountability and
delegation within scope.
Rationale — Incorrect:
A. Providing discharge teaching first ignores prioritization
of the unstable patient and risks harm.
B. Requesting reassignment may be appropriate in some
circumstances but immediate patient assessment and
delegation are more practical and timely.
D. Declining outright without attempting prioritization or
delegation fails to use clinical judgment and
interprofessional resources.
Teaching Point: Prioritize unstable patients; use delegation
appropriately to maintain safety.
Citation: Ignatavicius et al., 2024, Ch. 1: Roles and
Accountability
2
Reference: Ch. 2: Clinical Judgment and Systems Thinking
— Tanner’s Model and Decision Making
Question Stem: A patient with chronic heart failure reports
gradual weight gain and increased shortness of breath over
,48 hours. Following Tanner’s clinical judgment model, what
is the nurse’s next best action after noticing these data?
A. Document findings and reassess in 8 hours.
B. Call the provider to report possible fluid overload and
request diuretic order.
C. Increase the patient’s oral fluid intake to relieve thirst
from dry mouth.
D. Notify the dietitian to restrict sodium further.
Correct Answer: B
Rationale — Correct: Noticing worsening signs (weight
gain, dyspnea) suggests fluid overload; the nurse should
interpret and respond by communicating promptly to
obtain an order for treatment (e.g., diuretic), aligning with
clinical judgment and timely intervention.
Rationale — Incorrect:
A. Waiting delays necessary treatment and risks
deterioration.
C. Increasing fluids worsens volume overload in heart
failure.
D. Sodium restriction is a long-term plan and does not
address acute fluid accumulation.
Teaching Point: Recognize early decompensation and
communicate for immediate treatment.
Citation: Ignatavicius et al., 2024, Ch. 2: Tanner’s Model
and Clinical Decision Making
, 3
Reference: Ch. 3: Health Concepts — Mobility, Tissue
Integrity, and Risk Assessment
Question Stem: During morning rounds a nurse identifies a
previously mobile patient now complaining of new calf
pain and unilateral leg swelling. What action should the
nurse take first?
A. Apply warm compresses to the swollen calf and
ambulate the patient.
B. Measure calf circumferences, elevate the limb, and
notify the provider for suspected DVT.
C. Encourage the patient to perform ankle pumps and
continue routine care.
D. Administer PRN analgesic and document findings.
Correct Answer: B
Rationale — Correct: New unilateral swelling and calf pain
raise concern for deep vein thrombosis; immediate
measurement, limb elevation, and provider notification for
diagnostic testing and anticoagulation decisions is priority
to prevent embolism.
Rationale — Incorrect:
A. Ambulation and warm compresses before evaluation
could dislodge a thrombus.
C. Encouraging activity without assessment risks harm if
DVT present.
D. Analgesia alone treats symptom but fails to address
potentially life-threatening cause.
