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: Professional Nursing Concepts — Clinical
Judgment & QSEN Competencies
Question Stem: During admission a middle-aged post-op
patient with abdominal surgery reports mild shortness of
breath and O₂ saturation 92% on room air. Which nursing
action best reflects clinical judgment and immediate
priority?
A. Document the findings and reassess in 2 hours.
B. Encourage deep breathing and coughing and place the
patient in Fowler’s position.
C. Administer PRN opioid analgesic to reduce pain before
deep breathing.
D. Notify the surgeon for potential pulmonary embolism.
Correct Answer: B
Rationale (Correct): Positioning upright and encouraging
deep breathing/coughing addresses hypoventilation and
,atelectasis risk, immediate, evidence-based nursing
interventions to improve oxygenation. This is an
appropriate first action per the nursing process and QSEN
safety focus.
Rationale (A): Waiting 2 hours delays intervention for
borderline hypoxia and risks deterioration.
Rationale (C): Giving opioids may worsen respiratory drive
and should not precede nonpharmacologic measures
without assessment.
Rationale (D): Notifying the surgeon is premature; PE is
less likely than postoperative atelectasis — stabilize and
assess first.
Teaching Point: Prioritize airway/oxygenation and nurse-
initiated interventions before escalation.
Citation: Ignatavicius et al., 2024, Ch. 1: Professional
Nursing Concepts — Clinical Judgment & Safety
2
Reference: Ch. 2: Clinical Judgment and Systems Thinking
— Data Interpretation & Hypothesis Generation
Question Stem: A nurse is caring for four patients. Which
assessment finding should the nurse evaluate first using
clinical judgment?
A. A diabetic patient with blood glucose 210 mg/dL and +2
urine ketones.
,B. A patient 12 hours post-op with a firm, tender abdomen
and absent bowel sounds.
C. A postoperative patient with serosanguineous drainage
on dressing.
D. A patient with intermittent atrial fibrillation and heart
rate 86 bpm.
Correct Answer: B
Rationale (Correct): A firm, tender abdomen with absent
bowel sounds 12 hours post-op may indicate postoperative
ileus, obstruction, or peritonitis — potential surgical
emergency requiring prompt evaluation. Systems thinking
prioritizes findings that suggest rapid deterioration.
Rationale (A): Hyperglycemia with ketones is concerning
but, depending on symptoms, often less immediately life-
threatening than suspected acute abdomen.
Rationale (C): Serosanguineous drainage can be expected
postoperatively and is lower priority if vitals stable.
Rationale (D): Afib with HR 86 is rate controlled and not
immediately critical compared to acute abdominal signs.
Teaching Point: Prioritize assessment findings that indicate
imminent physiologic deterioration.
Citation: Ignatavicius et al., 2024, Ch. 2: Clinical Judgment
and Systems Thinking — Data Interpretation
3
, Reference: Ch. 3: Health Concepts — Infection Prevention
& Standard Precautions
Question Stem: A patient with suspected C. difficile
infection requires nursing care. Which action best reduces
transmission risk while providing necessary care?
A. Wear gloves and a surgical mask when entering the
room.
B. Use alcohol-based hand rub before and after patient
contact.
C. Don gown and gloves and perform handwashing with
soap and water on exit.
D. Place the patient on airborne precautions.
Correct Answer: C
Rationale (Correct): C. difficile spores are resistant to
alcohol; gown and gloves plus soap-and-water
handwashing on exit are recommended to prevent
transmission. This aligns with infection prevention
principles.
Rationale (A): A mask is not required for contact
precautions; gloves alone are insufficient.
Rationale (B): Alcohol hand rub is ineffective against C.
difficile spores.
Rationale (D): Airborne precautions are unnecessary for C.
difficile; contact precautions are appropriate.
Teaching Point: For C. difficile, use contact precautions and
soap-and-water handwashing.
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: Professional Nursing Concepts — Clinical
Judgment & QSEN Competencies
Question Stem: During admission a middle-aged post-op
patient with abdominal surgery reports mild shortness of
breath and O₂ saturation 92% on room air. Which nursing
action best reflects clinical judgment and immediate
priority?
A. Document the findings and reassess in 2 hours.
B. Encourage deep breathing and coughing and place the
patient in Fowler’s position.
C. Administer PRN opioid analgesic to reduce pain before
deep breathing.
D. Notify the surgeon for potential pulmonary embolism.
Correct Answer: B
Rationale (Correct): Positioning upright and encouraging
deep breathing/coughing addresses hypoventilation and
,atelectasis risk, immediate, evidence-based nursing
interventions to improve oxygenation. This is an
appropriate first action per the nursing process and QSEN
safety focus.
Rationale (A): Waiting 2 hours delays intervention for
borderline hypoxia and risks deterioration.
Rationale (C): Giving opioids may worsen respiratory drive
and should not precede nonpharmacologic measures
without assessment.
Rationale (D): Notifying the surgeon is premature; PE is
less likely than postoperative atelectasis — stabilize and
assess first.
Teaching Point: Prioritize airway/oxygenation and nurse-
initiated interventions before escalation.
Citation: Ignatavicius et al., 2024, Ch. 1: Professional
Nursing Concepts — Clinical Judgment & Safety
2
Reference: Ch. 2: Clinical Judgment and Systems Thinking
— Data Interpretation & Hypothesis Generation
Question Stem: A nurse is caring for four patients. Which
assessment finding should the nurse evaluate first using
clinical judgment?
A. A diabetic patient with blood glucose 210 mg/dL and +2
urine ketones.
,B. A patient 12 hours post-op with a firm, tender abdomen
and absent bowel sounds.
C. A postoperative patient with serosanguineous drainage
on dressing.
D. A patient with intermittent atrial fibrillation and heart
rate 86 bpm.
Correct Answer: B
Rationale (Correct): A firm, tender abdomen with absent
bowel sounds 12 hours post-op may indicate postoperative
ileus, obstruction, or peritonitis — potential surgical
emergency requiring prompt evaluation. Systems thinking
prioritizes findings that suggest rapid deterioration.
Rationale (A): Hyperglycemia with ketones is concerning
but, depending on symptoms, often less immediately life-
threatening than suspected acute abdomen.
Rationale (C): Serosanguineous drainage can be expected
postoperatively and is lower priority if vitals stable.
Rationale (D): Afib with HR 86 is rate controlled and not
immediately critical compared to acute abdominal signs.
Teaching Point: Prioritize assessment findings that indicate
imminent physiologic deterioration.
Citation: Ignatavicius et al., 2024, Ch. 2: Clinical Judgment
and Systems Thinking — Data Interpretation
3
, Reference: Ch. 3: Health Concepts — Infection Prevention
& Standard Precautions
Question Stem: A patient with suspected C. difficile
infection requires nursing care. Which action best reduces
transmission risk while providing necessary care?
A. Wear gloves and a surgical mask when entering the
room.
B. Use alcohol-based hand rub before and after patient
contact.
C. Don gown and gloves and perform handwashing with
soap and water on exit.
D. Place the patient on airborne precautions.
Correct Answer: C
Rationale (Correct): C. difficile spores are resistant to
alcohol; gown and gloves plus soap-and-water
handwashing on exit are recommended to prevent
transmission. This aligns with infection prevention
principles.
Rationale (A): A mask is not required for contact
precautions; gloves alone are insufficient.
Rationale (B): Alcohol hand rub is ineffective against C.
difficile spores.
Rationale (D): Airborne precautions are unnecessary for C.
difficile; contact precautions are appropriate.
Teaching Point: For C. difficile, use contact precautions and
soap-and-water handwashing.
