Linton and Matteson's Medical-Surgical
Practical Nursing in Canada, 1st Edition
Authors:
Katherine Poser,Adrianne Dill Linton,Mary
Ann Matteson
TEST BANK.
Medical–Surgical Practical Nursing — Test Bank
Chapter 1: Aspects of Medical-Surgical Nursing
1. (Standard) A 72-year-old postoperative client is mildly
confused and has a respiratory rate of 10 breaths/min,
oxygen saturation 90% on room air, and a blood pressure
of 98/60 mm Hg. As the PN, which action should you take
first?
, A. Give PRN acetaminophen for mild confusion.
B. Place the client in high Fowler’s position and encourage
deep breaths.
C. Administer supplemental oxygen per protocol and
reassess oxygenation.
D. Call the RN to report a change in mental status.
Answer: C. Administer supplemental oxygen per protocol and
reassess oxygenation.
Rationale: Hypoxia can present as confusion in older adults;
immediate oxygenation correction is the priority intervention
before reporting or comfort measures. PN scope typically
includes implementing delegated standing orders for oxygen
and reassessment.
Citation: Linton & Matteson, 1st ed., Unit I — Aspects of
Medical-Surgical Nursing (Chapter 1).
2. (Priority) During shift report, you learn a client with
chronic obstructive pulmonary disease (COPD) is less
responsive and using accessory muscles. Which nursing
action is highest priority?
A. Increase the frequency of respiratory assessments to
q15 min.
B. Administer prescribed short-acting bronchodilator via
nebulizer immediately.
C. Encourage pursed-lip breathing and positioning.
, D. Prepare to call the RN for possible transfer to a higher
level of care.
Answer: B. Administer prescribed short-acting bronchodilator
via nebulizer immediately.
Rationale: Active respiratory compromise requires immediate
pharmacologic bronchodilation to reverse airflow limitation;
interventions to support breathing are secondary but should
follow quickly. PN may administer bronchodilators per order
and standing protocols.
Citation: Linton & Matteson, 1st ed., Unit I — Aspects of
Medical-Surgical Nursing (Chapter 1).
3. (SATA) Which elements should the PN include when
performing a focused safety check on admission to a
medical-surgical unit? (Select all that apply.)
A. Confirm patient identity using two identifiers.
B. Assess fall risk and implement appropriate precautions.
C. Complete a full physical head-to-toe assessment.
D. Verify allergies and current medication list.
E. Review advance directives only if the client requests.
Answer: A, B, D.
Rationale: Safety checks should always include identity
verification, fall-risk assessment and precautions, and
medication/allergy verification. A full head-to-toe exam is
comprehensive and often done later; advance directives should
be identified but not deferred only to client request.
, Citation: Linton & Matteson, 1st ed., Unit I — Aspects of
Medical-Surgical Nursing (Chapter 1).
4. (Scenario — Priority) A PN cares for four clients. Which
client should the PN assess first?
A. A client 1 hour post-op with pain 6/10 controlled with
PCA settings.
B. A client with type 2 diabetes whose capillary glucose is
4.0 mmol/L and is asymptomatic.
C. A client on warfarin with new ecchymoses on the
abdomen and INR pending.
D. A client with a chest tube with gentle continuous
bubbling in the suction control chamber.
Answer: C. A client on warfarin with new ecchymoses on the
abdomen and INR pending.
Rationale: New bleeding signs (ecchymoses) indicate possible
coagulopathy and risk of major hemorrhage; immediate
assessment and communication are required. The others are
stable or expected findings (PCA, mild hypoglycemia borderline
but asymptomatic, continuous gentle bubbling can be normal
depending on system).
Citation: Linton & Matteson, 1st ed., Unit I — Aspects of
Medical-Surgical Nursing (Chapter 1).
Practical Nursing in Canada, 1st Edition
Authors:
Katherine Poser,Adrianne Dill Linton,Mary
Ann Matteson
TEST BANK.
Medical–Surgical Practical Nursing — Test Bank
Chapter 1: Aspects of Medical-Surgical Nursing
1. (Standard) A 72-year-old postoperative client is mildly
confused and has a respiratory rate of 10 breaths/min,
oxygen saturation 90% on room air, and a blood pressure
of 98/60 mm Hg. As the PN, which action should you take
first?
, A. Give PRN acetaminophen for mild confusion.
B. Place the client in high Fowler’s position and encourage
deep breaths.
C. Administer supplemental oxygen per protocol and
reassess oxygenation.
D. Call the RN to report a change in mental status.
Answer: C. Administer supplemental oxygen per protocol and
reassess oxygenation.
Rationale: Hypoxia can present as confusion in older adults;
immediate oxygenation correction is the priority intervention
before reporting or comfort measures. PN scope typically
includes implementing delegated standing orders for oxygen
and reassessment.
Citation: Linton & Matteson, 1st ed., Unit I — Aspects of
Medical-Surgical Nursing (Chapter 1).
2. (Priority) During shift report, you learn a client with
chronic obstructive pulmonary disease (COPD) is less
responsive and using accessory muscles. Which nursing
action is highest priority?
A. Increase the frequency of respiratory assessments to
q15 min.
B. Administer prescribed short-acting bronchodilator via
nebulizer immediately.
C. Encourage pursed-lip breathing and positioning.
, D. Prepare to call the RN for possible transfer to a higher
level of care.
Answer: B. Administer prescribed short-acting bronchodilator
via nebulizer immediately.
Rationale: Active respiratory compromise requires immediate
pharmacologic bronchodilation to reverse airflow limitation;
interventions to support breathing are secondary but should
follow quickly. PN may administer bronchodilators per order
and standing protocols.
Citation: Linton & Matteson, 1st ed., Unit I — Aspects of
Medical-Surgical Nursing (Chapter 1).
3. (SATA) Which elements should the PN include when
performing a focused safety check on admission to a
medical-surgical unit? (Select all that apply.)
A. Confirm patient identity using two identifiers.
B. Assess fall risk and implement appropriate precautions.
C. Complete a full physical head-to-toe assessment.
D. Verify allergies and current medication list.
E. Review advance directives only if the client requests.
Answer: A, B, D.
Rationale: Safety checks should always include identity
verification, fall-risk assessment and precautions, and
medication/allergy verification. A full head-to-toe exam is
comprehensive and often done later; advance directives should
be identified but not deferred only to client request.
, Citation: Linton & Matteson, 1st ed., Unit I — Aspects of
Medical-Surgical Nursing (Chapter 1).
4. (Scenario — Priority) A PN cares for four clients. Which
client should the PN assess first?
A. A client 1 hour post-op with pain 6/10 controlled with
PCA settings.
B. A client with type 2 diabetes whose capillary glucose is
4.0 mmol/L and is asymptomatic.
C. A client on warfarin with new ecchymoses on the
abdomen and INR pending.
D. A client with a chest tube with gentle continuous
bubbling in the suction control chamber.
Answer: C. A client on warfarin with new ecchymoses on the
abdomen and INR pending.
Rationale: New bleeding signs (ecchymoses) indicate possible
coagulopathy and risk of major hemorrhage; immediate
assessment and communication are required. The others are
stable or expected findings (PCA, mild hypoglycemia borderline
but asymptomatic, continuous gentle bubbling can be normal
depending on system).
Citation: Linton & Matteson, 1st ed., Unit I — Aspects of
Medical-Surgical Nursing (Chapter 1).
