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. 2: Clinical Judgment and Systems Thinking —
Clinical Decision-Making: Recognizing Cues and Prioritizing Care
Question stem: A 72-year-old post-op hip replacement patient
reports sudden chest discomfort and shortness of breath 18
hours after surgery. Pulse 110, BP 130/78, RR 28, SpO₂ 88% on
room air. Which action should the nurse perform first?
A. Administer PRN opioid for pain.
B. Apply oxygen via nasal cannula at 2 L/min and reassess SpO₂.
C. Reassess pain level and check the surgical dressing.
D. Encourage deep-breathing and incentive spirometry.
Correct answer: B
Rationale (correct): Applying oxygen is the immediate
intervention to correct hypoxemia (SpO₂ 88%) and is essential
,while further assessment proceeds; stabilizing oxygenation
reduces risk of deterioration. (Ch. 2: prioritization of immediate
physiologic threats.)
Rationale (A): Opioid could worsen respiratory depression and
hypoxemia; pain control is important but not first when
oxygenation is low.
Rationale (C): Checking dressing is lower priority relative to
hypoxemia and respiratory distress.
Rationale (D): Encouraging breathing is appropriate but less
urgent than providing supplemental oxygen to correct SpO₂
88%.
Teaching point: Treat hypoxemia first — secure oxygenation
before nonurgent tasks.
Citation: Ignatavicius et al., 2024, Ch. 2: Clinical Decision-
Making.
2
Reference: Ch. 1: Overview of Professional Nursing Concepts —
Scope, Accountability, and Delegation
Question stem: Which task is appropriate to delegate to a
licensed practical nurse (LPN/LVN) for a medically stable
postoperative patient?
A. Perform the initial admission nursing assessment.
B. Administer scheduled subcutaneous heparin and document
site.
C. Develop the patient’s individualized discharge education
,plan.
D. Evaluate the patient’s response to newly prescribed opioid.
Correct answer: B
Rationale (correct): Administering and documenting routine
subcutaneous injections for stable patients is within LPN scope
under RN supervision; it’s a safe, delegated technical task. (Ch.
1: delegation principles.)
Rationale (A): Initial comprehensive RN assessment requires RN
critical thinking and is not delegable.
Rationale (C): Developing individualized discharge teaching is
an RN responsibility involving assessment and teaching.
Rationale (D): Evaluating response to a new opioid requires RN
judgment for monitoring adverse effects and titration.
Teaching point: Delegate stable, routine technical tasks; retain
assessment and evaluation.
Citation: Ignatavicius et al., 2024, Ch. 1: Delegation and
Accountability.
3
Reference: Ch. 3: Overview of Health Concepts — Fluid and
Electrolyte Balance
Question stem: A patient with chronic heart failure has 2+
pitting edema, crackles bilaterally, BNP elevated, and is on
furosemide 40 mg daily. Today the nurse notes urine output 80
mL in 8 hours and weight gain of 1.5 kg since yesterday. What is
the nurse’s best next action?
, A. Hold the morning dose of furosemide and notify the
provider.
B. Encourage the patient to drink more fluids to increase urine
output.
C. Assess vitals, check serum electrolytes, and notify the
provider about reduced urine output.
D. Apply compression stockings and reweigh in 12 hours.
Correct answer: C
Rationale (correct): Reduced urine output and rapid weight
gain in HF require assessment (vitals, labs) and prompt
communication — electrolytes and renal function guide diuretic
adjustments. (Ch. 3: F/E and organ perfusion.)
Rationale (A): Holding diuretic without assessment may worsen
volume overload; decision should be provider-directed after
data.
Rationale (B): Encouraging fluids is inappropriate in volume-
overloaded HF.
Rationale (D): Compression stockings do not address acute
retention or pulmonary fluid and delay needed assessment.
Teaching point: Assess & report changes in output/weight; lab
data guide diuretic management.
Citation: Ignatavicius et al., 2024, Ch. 3: Fluid and Electrolyte
Balance.
4
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. 2: Clinical Judgment and Systems Thinking —
Clinical Decision-Making: Recognizing Cues and Prioritizing Care
Question stem: A 72-year-old post-op hip replacement patient
reports sudden chest discomfort and shortness of breath 18
hours after surgery. Pulse 110, BP 130/78, RR 28, SpO₂ 88% on
room air. Which action should the nurse perform first?
A. Administer PRN opioid for pain.
B. Apply oxygen via nasal cannula at 2 L/min and reassess SpO₂.
C. Reassess pain level and check the surgical dressing.
D. Encourage deep-breathing and incentive spirometry.
Correct answer: B
Rationale (correct): Applying oxygen is the immediate
intervention to correct hypoxemia (SpO₂ 88%) and is essential
,while further assessment proceeds; stabilizing oxygenation
reduces risk of deterioration. (Ch. 2: prioritization of immediate
physiologic threats.)
Rationale (A): Opioid could worsen respiratory depression and
hypoxemia; pain control is important but not first when
oxygenation is low.
Rationale (C): Checking dressing is lower priority relative to
hypoxemia and respiratory distress.
Rationale (D): Encouraging breathing is appropriate but less
urgent than providing supplemental oxygen to correct SpO₂
88%.
Teaching point: Treat hypoxemia first — secure oxygenation
before nonurgent tasks.
Citation: Ignatavicius et al., 2024, Ch. 2: Clinical Decision-
Making.
2
Reference: Ch. 1: Overview of Professional Nursing Concepts —
Scope, Accountability, and Delegation
Question stem: Which task is appropriate to delegate to a
licensed practical nurse (LPN/LVN) for a medically stable
postoperative patient?
A. Perform the initial admission nursing assessment.
B. Administer scheduled subcutaneous heparin and document
site.
C. Develop the patient’s individualized discharge education
,plan.
D. Evaluate the patient’s response to newly prescribed opioid.
Correct answer: B
Rationale (correct): Administering and documenting routine
subcutaneous injections for stable patients is within LPN scope
under RN supervision; it’s a safe, delegated technical task. (Ch.
1: delegation principles.)
Rationale (A): Initial comprehensive RN assessment requires RN
critical thinking and is not delegable.
Rationale (C): Developing individualized discharge teaching is
an RN responsibility involving assessment and teaching.
Rationale (D): Evaluating response to a new opioid requires RN
judgment for monitoring adverse effects and titration.
Teaching point: Delegate stable, routine technical tasks; retain
assessment and evaluation.
Citation: Ignatavicius et al., 2024, Ch. 1: Delegation and
Accountability.
3
Reference: Ch. 3: Overview of Health Concepts — Fluid and
Electrolyte Balance
Question stem: A patient with chronic heart failure has 2+
pitting edema, crackles bilaterally, BNP elevated, and is on
furosemide 40 mg daily. Today the nurse notes urine output 80
mL in 8 hours and weight gain of 1.5 kg since yesterday. What is
the nurse’s best next action?
, A. Hold the morning dose of furosemide and notify the
provider.
B. Encourage the patient to drink more fluids to increase urine
output.
C. Assess vitals, check serum electrolytes, and notify the
provider about reduced urine output.
D. Apply compression stockings and reweigh in 12 hours.
Correct answer: C
Rationale (correct): Reduced urine output and rapid weight
gain in HF require assessment (vitals, labs) and prompt
communication — electrolytes and renal function guide diuretic
adjustments. (Ch. 3: F/E and organ perfusion.)
Rationale (A): Holding diuretic without assessment may worsen
volume overload; decision should be provider-directed after
data.
Rationale (B): Encouraging fluids is inappropriate in volume-
overloaded HF.
Rationale (D): Compression stockings do not address acute
retention or pulmonary fluid and delay needed assessment.
Teaching point: Assess & report changes in output/weight; lab
data guide diuretic management.
Citation: Ignatavicius et al., 2024, Ch. 3: Fluid and Electrolyte
Balance.
4
