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. 1: Professional Roles and Scope —
Interprofessional Collaboration
Question Stem: A 68-year-old man with COPD is admitted for
acute exacerbation. The nurse notes a discharge plan is needed
within 48 hours. Which action should the nurse prioritize first to
promote safe discharge planning?
A. Teach inhaler technique to the patient.
B. Contact home health to arrange nursing visits.
C. Assess the patient’s ability to perform activities of daily living
(ADLs).
D. Provide written education about oxygen safety.
Correct Answer: C
Rationales:
, • Correct (C): Assessing ADL ability identifies functional
deficits that directly affect discharge readiness and
determines appropriate referrals. This assessment guides
individualized, safe discharge planning.
• A: Teaching inhaler technique is essential but should follow
assessment of learning needs and functional ability.
• B: Contacting home health is appropriate if deficits exist,
but referrals should be based on assessment findings.
• D: Providing oxygen safety education is important when
oxygen is used, but the nurse must first determine patient
needs and abilities.
Teaching Point: Start discharge planning with a functional and
psychosocial assessment.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Professional Roles and Scope
2
Reference: Ch. 2: Clinical Judgment and Systems Thinking —
Priority Setting & Clinical Judgment
Question Stem: A postoperative patient on the med-surg unit
reports sudden shortness of breath and pleuritic chest pain 2
days after hip arthroplasty. Vital signs: T 37°C, HR 116, RR 28, BP
110/64, SpO₂ 88% on room air. What is the nurse’s best first
action?
,A. Encourage deep breathing and coughing exercises.
B. Apply supplemental oxygen and call the provider for
suspected pulmonary embolism.
C. Administer PRN opioid for pain to facilitate breathing.
D. Elevate the head of the bed and obtain a chest x-ray.
Correct Answer: B
Rationales:
• Correct (B): Sudden dyspnea, tachycardia, tachypnea, and
hypoxemia after orthopedic surgery suggests pulmonary
embolism — immediate oxygen and provider notification
are priority actions.
• A: Deep breathing/coughing is appropriate for atelectasis
prevention but insufficient for acute hypoxemia and
suspected embolus.
• C: Opioids may depress respirations and mask symptoms;
not first-line for suspected PE.
• D: Elevating head helps respiratory effort but chest x-ray
will not confirm PE and delays urgent oxygen and
evaluation.
Teaching Point: Rapid recognition and oxygenation are
priorities for suspected pulmonary embolism.
Citation: Ignatavicius et al., 2024, Ch. 2: Clinical Judgment and
Systems Thinking
, 3
Reference: Ch. 3: Health Concepts — Fluid and Electrolyte
Balance
Question Stem: A patient with heart failure has sudden weight
gain of 2.3 kg (5 lb) in 48 hours, increased peripheral edema,
and shortness of breath. Which nursing intervention best
reflects priority clinical judgment?
A. Reinforce low-sodium diet teaching.
B. Administer prescribed IV furosemide and monitor urine
output.
C. Weigh the patient again in the morning.
D. Encourage ambulation and leg elevation.
Correct Answer: B
Rationales:
• Correct (B): Acute fluid overload with respiratory
symptoms and rapid weight gain requires prompt diuresis
and monitoring to reduce preload and relieve symptoms.
• A: Diet teaching is important for long-term management
but not the immediate priority in acute fluid overload.
• C: Reweighing later delays needed treatment.
• D: Ambulation and leg elevation may assist venous return
but are secondary to active diuresis in symptomatic fluid
overload.
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. 1: Professional Roles and Scope —
Interprofessional Collaboration
Question Stem: A 68-year-old man with COPD is admitted for
acute exacerbation. The nurse notes a discharge plan is needed
within 48 hours. Which action should the nurse prioritize first to
promote safe discharge planning?
A. Teach inhaler technique to the patient.
B. Contact home health to arrange nursing visits.
C. Assess the patient’s ability to perform activities of daily living
(ADLs).
D. Provide written education about oxygen safety.
Correct Answer: C
Rationales:
, • Correct (C): Assessing ADL ability identifies functional
deficits that directly affect discharge readiness and
determines appropriate referrals. This assessment guides
individualized, safe discharge planning.
• A: Teaching inhaler technique is essential but should follow
assessment of learning needs and functional ability.
• B: Contacting home health is appropriate if deficits exist,
but referrals should be based on assessment findings.
• D: Providing oxygen safety education is important when
oxygen is used, but the nurse must first determine patient
needs and abilities.
Teaching Point: Start discharge planning with a functional and
psychosocial assessment.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Professional Roles and Scope
2
Reference: Ch. 2: Clinical Judgment and Systems Thinking —
Priority Setting & Clinical Judgment
Question Stem: A postoperative patient on the med-surg unit
reports sudden shortness of breath and pleuritic chest pain 2
days after hip arthroplasty. Vital signs: T 37°C, HR 116, RR 28, BP
110/64, SpO₂ 88% on room air. What is the nurse’s best first
action?
,A. Encourage deep breathing and coughing exercises.
B. Apply supplemental oxygen and call the provider for
suspected pulmonary embolism.
C. Administer PRN opioid for pain to facilitate breathing.
D. Elevate the head of the bed and obtain a chest x-ray.
Correct Answer: B
Rationales:
• Correct (B): Sudden dyspnea, tachycardia, tachypnea, and
hypoxemia after orthopedic surgery suggests pulmonary
embolism — immediate oxygen and provider notification
are priority actions.
• A: Deep breathing/coughing is appropriate for atelectasis
prevention but insufficient for acute hypoxemia and
suspected embolus.
• C: Opioids may depress respirations and mask symptoms;
not first-line for suspected PE.
• D: Elevating head helps respiratory effort but chest x-ray
will not confirm PE and delays urgent oxygen and
evaluation.
Teaching Point: Rapid recognition and oxygenation are
priorities for suspected pulmonary embolism.
Citation: Ignatavicius et al., 2024, Ch. 2: Clinical Judgment and
Systems Thinking
, 3
Reference: Ch. 3: Health Concepts — Fluid and Electrolyte
Balance
Question Stem: A patient with heart failure has sudden weight
gain of 2.3 kg (5 lb) in 48 hours, increased peripheral edema,
and shortness of breath. Which nursing intervention best
reflects priority clinical judgment?
A. Reinforce low-sodium diet teaching.
B. Administer prescribed IV furosemide and monitor urine
output.
C. Weigh the patient again in the morning.
D. Encourage ambulation and leg elevation.
Correct Answer: B
Rationales:
• Correct (B): Acute fluid overload with respiratory
symptoms and rapid weight gain requires prompt diuresis
and monitoring to reduce preload and relieve symptoms.
• A: Diet teaching is important for long-term management
but not the immediate priority in acute fluid overload.
• C: Reweighing later delays needed treatment.
• D: Ambulation and leg elevation may assist venous return
but are secondary to active diuresis in symptomatic fluid
overload.
