Linton and Matteson's Medical-Surgical
Practical Nursing in Canada, 1st Edition
Authors:
Katherine Poser,Adrianne Dill Linton,Mary
Ann Matteson
TEST BANK.
Source: Linton and Matteson's Medical-Surgical Practical
Nursing in Canada
(Chapter used: Chapter 1 — Aspects of Medical-Surgical
Nursing)
1. (Standard — Single best answer)
A 72-year-old male admitted for management of
congestive heart failure has progressive dyspnea, a
, respiratory rate of 28/min, SpO₂ 88% on room air, and
bibasilar crackles. Which nursing action is the highest
priority?
A. Administer PRN opioid for anxiety.
B. Place the patient in high-Fowler’s position and give
supplemental oxygen.
C. Call the healthcare provider to request a chest x-ray.
D. Begin discharge teaching about fluid restriction.
Answer: B
Rationale: Airway/oxygenation is the immediate priority in ABC
framework; high-Fowler’s improves ventilation and oxygenation
and supplemental oxygen addresses hypoxemia before
diagnostics or teaching.
Citation: Chapter 1 — Aspects of Medical-Surgical Nursing
2. (Priority — First action)
A practical nurse receives a report: postoperative patient
with escalating heart rate (110 → 130), increasing
restlessness, and a drop in systolic BP from 120 to 90 mm
Hg over 30 minutes. What is the nurse’s first action?
A. Increase IV fluid infusion rate per protocol.
B. Perform a focused assessment including pain, surgical
site, and chest.
C. Notify the physician immediately.
D. Prepare for transfer to higher level of care.
,Answer: B
Rationale: Focused bedside assessment identifies the cause of
deterioration (bleeding, pain, hypovolemia, PE); assessment
guides appropriate immediate interventions and
communication.
Citation: Chapter 1 — Aspects of Medical-Surgical Nursing
3. (SATA — Select all that apply)
Which of the following interventions are appropriate
nursing actions when implementing the nursing process for
an older adult with impaired mobility? (Select all that
apply.)
A. Screen for fall risk and implement fall prevention
measures.
B. Assume the patient’s limited mobility means no further
ambulation attempts.
C. Collaborate with physiotherapy for progressive mobility
plan.
D. Teach the patient and family about safe transfer
techniques.
E. Document ambulation attempts, tolerance, and any
adverse responses.
Answers: A, C, D, E
Rationale: Fall risk screening, interdisciplinary collaboration,
patient/family teaching, and accurate documentation are
, essential. Avoid therapeutic pessimism (B).
Citation: Chapter 1 — Aspects of Medical-Surgical Nursing
4. (Scenario — Single best answer)
A 45-year-old with type 2 diabetes is admitted with a
nonhealing foot ulcer. The nurse notes the patient has
poor glycemic control, lives alone, and reports difficulty
buying food. Which nursing diagnosis should take priority
for discharge planning?
A. Risk for infection related to impaired skin integrity.
B. Ineffective health maintenance related to limited
resources.
C. Impaired tissue integrity related to peripheral vascular
disease.
D. Social isolation related to living alone.
Answer: B
Rationale: While infection and tissue integrity are clinical
concerns, ineffective health maintenance (limited resources
affecting ability to perform self-care and adhere to care plan)
will most influence long-term wound healing and must be
addressed for safe discharge planning.
Citation: Chapter 1 — Aspects of Medical-Surgical Nursing
5. (Standard)
During medication reconciliation on admission, the patient
Practical Nursing in Canada, 1st Edition
Authors:
Katherine Poser,Adrianne Dill Linton,Mary
Ann Matteson
TEST BANK.
Source: Linton and Matteson's Medical-Surgical Practical
Nursing in Canada
(Chapter used: Chapter 1 — Aspects of Medical-Surgical
Nursing)
1. (Standard — Single best answer)
A 72-year-old male admitted for management of
congestive heart failure has progressive dyspnea, a
, respiratory rate of 28/min, SpO₂ 88% on room air, and
bibasilar crackles. Which nursing action is the highest
priority?
A. Administer PRN opioid for anxiety.
B. Place the patient in high-Fowler’s position and give
supplemental oxygen.
C. Call the healthcare provider to request a chest x-ray.
D. Begin discharge teaching about fluid restriction.
Answer: B
Rationale: Airway/oxygenation is the immediate priority in ABC
framework; high-Fowler’s improves ventilation and oxygenation
and supplemental oxygen addresses hypoxemia before
diagnostics or teaching.
Citation: Chapter 1 — Aspects of Medical-Surgical Nursing
2. (Priority — First action)
A practical nurse receives a report: postoperative patient
with escalating heart rate (110 → 130), increasing
restlessness, and a drop in systolic BP from 120 to 90 mm
Hg over 30 minutes. What is the nurse’s first action?
A. Increase IV fluid infusion rate per protocol.
B. Perform a focused assessment including pain, surgical
site, and chest.
C. Notify the physician immediately.
D. Prepare for transfer to higher level of care.
,Answer: B
Rationale: Focused bedside assessment identifies the cause of
deterioration (bleeding, pain, hypovolemia, PE); assessment
guides appropriate immediate interventions and
communication.
Citation: Chapter 1 — Aspects of Medical-Surgical Nursing
3. (SATA — Select all that apply)
Which of the following interventions are appropriate
nursing actions when implementing the nursing process for
an older adult with impaired mobility? (Select all that
apply.)
A. Screen for fall risk and implement fall prevention
measures.
B. Assume the patient’s limited mobility means no further
ambulation attempts.
C. Collaborate with physiotherapy for progressive mobility
plan.
D. Teach the patient and family about safe transfer
techniques.
E. Document ambulation attempts, tolerance, and any
adverse responses.
Answers: A, C, D, E
Rationale: Fall risk screening, interdisciplinary collaboration,
patient/family teaching, and accurate documentation are
, essential. Avoid therapeutic pessimism (B).
Citation: Chapter 1 — Aspects of Medical-Surgical Nursing
4. (Scenario — Single best answer)
A 45-year-old with type 2 diabetes is admitted with a
nonhealing foot ulcer. The nurse notes the patient has
poor glycemic control, lives alone, and reports difficulty
buying food. Which nursing diagnosis should take priority
for discharge planning?
A. Risk for infection related to impaired skin integrity.
B. Ineffective health maintenance related to limited
resources.
C. Impaired tissue integrity related to peripheral vascular
disease.
D. Social isolation related to living alone.
Answer: B
Rationale: While infection and tissue integrity are clinical
concerns, ineffective health maintenance (limited resources
affecting ability to perform self-care and adhere to care plan)
will most influence long-term wound healing and must be
addressed for safe discharge planning.
Citation: Chapter 1 — Aspects of Medical-Surgical Nursing
5. (Standard)
During medication reconciliation on admission, the patient
