Linton and Matteson's Medical-Surgical
Practical Nursing in Canada, 1st Edition
Authors:
Katherine Poser,Adrianne Dill Linton,Mary
Ann Matteson
TEST BANK.
1
A 72-year-old postoperative patient has a blood pressure of
88/54 mm Hg, heart rate 110/min, respiratory rate 24/min, and
cool, pale skin. Which nursing action is the highest priority?
A. Reassess vital signs in 30 minutes.
B. Elevate the head of the bed to 45°.
C. Notify the surgeon or rapid response team immediately.
D. Offer oral fluids and recheck blood pressure.
,Correct: C
Rationale: Hypotension with tachycardia and cool, pale skin
indicates possible shock — immediate escalation (notify
surgeon/rapid response) is highest priority for prompt
assessment and intervention. (Nursing judgment & safety).
Citation: Linton & Matteson, Medical–Surgical Practical Nursing
in Canada, 1st ed., Chapter 1: Aspects of Medical–Surgical
Nursing.
2 (SATA)
Which of the following are responsibilities within the PN/LPN
scope when admitting a medical–surgical patient? (Select all
that apply.)
A. Perform a focused physical assessment and report abnormal
findings.
B. Diagnose the patient’s medical condition.
C. Administer medications per established protocols and
document.
D. Reinforce patient teaching provided by the RN.
E. Independently alter the plan of care without consulting the
RN.
Correct: A, C, D
Rationale: PNs perform focused assessments, administer meds
per protocols, and reinforce teaching. Diagnosing and
independently altering the plan of care are beyond typical PN
,scope and require RN/MD decision-making.
Citation: Linton & Matteson, 1st ed., Chapter 1.
3
Which statement best reflects the role of clinical judgment in
medical–surgical nursing?
A. It replaces the need for standardized protocols.
B. It combines knowledge, experience, and patient data to make
safe decisions.
C. It allows the nurse to practice without collaboration.
D. It focuses only on technical skills rather than thinking
processes.
Correct: B
Rationale: Clinical judgment integrates knowledge, experience,
and assessment data to prioritize and make safe patient-
centered decisions.
Citation: Linton & Matteson, 1st ed., Chapter 1.
4
A patient refuses a recommended wound dressing change
stating cultural concerns. Which is the most appropriate
immediate nursing response?
A. Tell the patient the dressing must be changed regardless of
feelings.
B. Document refusal and proceed with the dressing change.
, C. Explore the patient’s concerns and involve the health-care
team to seek alternatives.
D. Discharge the patient for noncompliance.
Correct: C
Rationale: Respectful exploration of cultural concerns,
collaboration, and searching for acceptable alternatives uphold
patient-centred care and legal/ethical practice.
Citation: Linton & Matteson, 1st ed., Chapter 1.
5 (Priority — clinical judgment)
A patient suddenly develops shortness of breath, agitation, and
oxygen saturation falls from 96% to 84%. Place the nurse’s
actions in order of priority (1 = first).
A. Apply supplemental oxygen and sit the patient upright.
B. Call for help/notify rapid response.
C. Auscultate breath sounds and check airway patency.
D. Reassess oxygen saturation and respiratory rate.
Correct order: A → C → D → B (1: A, 2: C, 3: D, 4: B)
Rationale: Immediate oxygenation and positioning first, quick
focused assessment (airway, breath sounds), reassessment to
evaluate response, then escalate if deterioration persists. Rapid
response may be called promptly if interventions fail — but
initial immediate measures are oxygen and airway.
Citation: Linton & Matteson, 1st ed., Chapter 1.
Practical Nursing in Canada, 1st Edition
Authors:
Katherine Poser,Adrianne Dill Linton,Mary
Ann Matteson
TEST BANK.
1
A 72-year-old postoperative patient has a blood pressure of
88/54 mm Hg, heart rate 110/min, respiratory rate 24/min, and
cool, pale skin. Which nursing action is the highest priority?
A. Reassess vital signs in 30 minutes.
B. Elevate the head of the bed to 45°.
C. Notify the surgeon or rapid response team immediately.
D. Offer oral fluids and recheck blood pressure.
,Correct: C
Rationale: Hypotension with tachycardia and cool, pale skin
indicates possible shock — immediate escalation (notify
surgeon/rapid response) is highest priority for prompt
assessment and intervention. (Nursing judgment & safety).
Citation: Linton & Matteson, Medical–Surgical Practical Nursing
in Canada, 1st ed., Chapter 1: Aspects of Medical–Surgical
Nursing.
2 (SATA)
Which of the following are responsibilities within the PN/LPN
scope when admitting a medical–surgical patient? (Select all
that apply.)
A. Perform a focused physical assessment and report abnormal
findings.
B. Diagnose the patient’s medical condition.
C. Administer medications per established protocols and
document.
D. Reinforce patient teaching provided by the RN.
E. Independently alter the plan of care without consulting the
RN.
Correct: A, C, D
Rationale: PNs perform focused assessments, administer meds
per protocols, and reinforce teaching. Diagnosing and
independently altering the plan of care are beyond typical PN
,scope and require RN/MD decision-making.
Citation: Linton & Matteson, 1st ed., Chapter 1.
3
Which statement best reflects the role of clinical judgment in
medical–surgical nursing?
A. It replaces the need for standardized protocols.
B. It combines knowledge, experience, and patient data to make
safe decisions.
C. It allows the nurse to practice without collaboration.
D. It focuses only on technical skills rather than thinking
processes.
Correct: B
Rationale: Clinical judgment integrates knowledge, experience,
and assessment data to prioritize and make safe patient-
centered decisions.
Citation: Linton & Matteson, 1st ed., Chapter 1.
4
A patient refuses a recommended wound dressing change
stating cultural concerns. Which is the most appropriate
immediate nursing response?
A. Tell the patient the dressing must be changed regardless of
feelings.
B. Document refusal and proceed with the dressing change.
, C. Explore the patient’s concerns and involve the health-care
team to seek alternatives.
D. Discharge the patient for noncompliance.
Correct: C
Rationale: Respectful exploration of cultural concerns,
collaboration, and searching for acceptable alternatives uphold
patient-centred care and legal/ethical practice.
Citation: Linton & Matteson, 1st ed., Chapter 1.
5 (Priority — clinical judgment)
A patient suddenly develops shortness of breath, agitation, and
oxygen saturation falls from 96% to 84%. Place the nurse’s
actions in order of priority (1 = first).
A. Apply supplemental oxygen and sit the patient upright.
B. Call for help/notify rapid response.
C. Auscultate breath sounds and check airway patency.
D. Reassess oxygen saturation and respiratory rate.
Correct order: A → C → D → B (1: A, 2: C, 3: D, 4: B)
Rationale: Immediate oxygenation and positioning first, quick
focused assessment (airway, breath sounds), reassessment to
evaluate response, then escalate if deterioration persists. Rapid
response may be called promptly if interventions fail — but
initial immediate measures are oxygen and airway.
Citation: Linton & Matteson, 1st ed., Chapter 1.
