Linton and Matteson's Medical-Surgical
Practical Nursing in Canada, 1st Edition
Authors:
Katherine Poser,Adrianne Dill Linton,Mary
Ann Matteson
TEST BANK.
Linton and Matteson’s Medical-Surgical Practical Nursing in
Canada
Unit I — Aspects of Medical-Surgical Nursing (Chapter 1)
Source for every item below: Linton & Matteson’s Medical-
Surgical Practical Nursing in Canada, 1st ed., Unit I: Aspects of
Medical-Surgical Nursing (Chapter 1).
Below are 20 high-difficulty, NCLEX-style items (mixed formats)
tailored to Practical Nursing students. Each item shows the
type, answer(s), a concise exam-focused rationale, and the
chapter citation.
, 1. (Standard — Single best answer)
A 72-year-old female is admitted for progressive dyspnea
and lower extremity swelling. During admission, she
reports taking several prescribed and OTC meds but cannot
recall all names. Which action should the practical nurse
prioritize first?
A. Begin bedside weight monitoring twice daily.
B. Obtain a complete medication reconciliation, including
OTCs and herbal remedies.
C. Start a low-sodium diet and provide patient education.
D. Notify the physician that the patient may need diuretic
therapy.
Answer: B. Obtain a complete medication reconciliation,
including OTCs and herbal remedies.
Rationale: Accurate medication history is foundational for safe
immediate care (identifies meds that could worsen heart
failure, cause interactions, or require withholding). Other
measures are important but secondary until medications are
known.
Citation: Unit I: Aspects of Medical-Surgical Nursing (Chapter 1).
2. (Priority — First-action)
A patient on the med-surgical floor reports sudden onset
substernal chest pain rated 8/10 and appears diaphoretic.
The practical nurse’s first action is to:
, A. Obtain a 12-lead ECG.
B. Administer PRN nitroglycerin.
C. Assess airway, breathing, and circulation (ABCs) and vital
signs.
D. Give aspirin per standing orders.
Answer: C. Assess airway, breathing, and circulation (ABCs) and
vital signs.
Rationale: Immediate assessment of ABCs and vital signs
determines stability and guides urgency of subsequent
interventions; it’s the safety-first priority before diagnostic or
medication actions.
Citation: Unit I: Aspects of Medical-Surgical Nursing (Chapter 1).
3. (SATA — Select all that apply)
Which tasks may a practical nurse appropriately delegate
to unregulated assistive personnel (UAP) on a stable
medical-surgical unit? (Select all that apply.)
A. Measure and record routine vital signs for a stable
patient.
B. Administer oral antibiotics.
C. Assist a stable patient with ambulation to the bathroom.
D. Perform nail care for a patient with diabetes.
E. Report abnormal findings to the nurse immediately.
Answers: A, C, E.
Rationale: UAPs may perform routine vital signs and assist with
ambulation and must report abnormal findings. Medication
, administration and specialized diabetic foot/nail care are
nursing responsibilities due to assessment and scope concerns.
Citation: Unit I: Aspects of Medical-Surgical Nursing (Chapter 1).
4. (Standard — Single best answer)
Lab values show rising BUN and creatinine over 24 hours
for a patient receiving multiple nephrotoxic agents. The
practical nurse should first:
A. Hold all scheduled oral medications.
B. Assess recent intake and output and urine
characteristics.
C. Prepare the patient for dialysis.
D. Increase oral fluids immediately.
Answer: B. Assess recent intake and output and urine
characteristics.
Rationale: Assessment of fluid balance and urine output is the
immediate nursing action to determine acute changes; holding
meds or starting treatments should follow assessment and
orders. Increasing fluids without assessing may be harmful.
Citation: Unit I: Aspects of Medical-Surgical Nursing (Chapter 1).
5. (Priority — First-action / Scenario)
A postoperative patient received IV morphine 30 minutes
ago and is now drowsy with a respiratory rate of 8
breaths/min and O₂ saturation 88%. What is the practical
Practical Nursing in Canada, 1st Edition
Authors:
Katherine Poser,Adrianne Dill Linton,Mary
Ann Matteson
TEST BANK.
Linton and Matteson’s Medical-Surgical Practical Nursing in
Canada
Unit I — Aspects of Medical-Surgical Nursing (Chapter 1)
Source for every item below: Linton & Matteson’s Medical-
Surgical Practical Nursing in Canada, 1st ed., Unit I: Aspects of
Medical-Surgical Nursing (Chapter 1).
Below are 20 high-difficulty, NCLEX-style items (mixed formats)
tailored to Practical Nursing students. Each item shows the
type, answer(s), a concise exam-focused rationale, and the
chapter citation.
, 1. (Standard — Single best answer)
A 72-year-old female is admitted for progressive dyspnea
and lower extremity swelling. During admission, she
reports taking several prescribed and OTC meds but cannot
recall all names. Which action should the practical nurse
prioritize first?
A. Begin bedside weight monitoring twice daily.
B. Obtain a complete medication reconciliation, including
OTCs and herbal remedies.
C. Start a low-sodium diet and provide patient education.
D. Notify the physician that the patient may need diuretic
therapy.
Answer: B. Obtain a complete medication reconciliation,
including OTCs and herbal remedies.
Rationale: Accurate medication history is foundational for safe
immediate care (identifies meds that could worsen heart
failure, cause interactions, or require withholding). Other
measures are important but secondary until medications are
known.
Citation: Unit I: Aspects of Medical-Surgical Nursing (Chapter 1).
2. (Priority — First-action)
A patient on the med-surgical floor reports sudden onset
substernal chest pain rated 8/10 and appears diaphoretic.
The practical nurse’s first action is to:
, A. Obtain a 12-lead ECG.
B. Administer PRN nitroglycerin.
C. Assess airway, breathing, and circulation (ABCs) and vital
signs.
D. Give aspirin per standing orders.
Answer: C. Assess airway, breathing, and circulation (ABCs) and
vital signs.
Rationale: Immediate assessment of ABCs and vital signs
determines stability and guides urgency of subsequent
interventions; it’s the safety-first priority before diagnostic or
medication actions.
Citation: Unit I: Aspects of Medical-Surgical Nursing (Chapter 1).
3. (SATA — Select all that apply)
Which tasks may a practical nurse appropriately delegate
to unregulated assistive personnel (UAP) on a stable
medical-surgical unit? (Select all that apply.)
A. Measure and record routine vital signs for a stable
patient.
B. Administer oral antibiotics.
C. Assist a stable patient with ambulation to the bathroom.
D. Perform nail care for a patient with diabetes.
E. Report abnormal findings to the nurse immediately.
Answers: A, C, E.
Rationale: UAPs may perform routine vital signs and assist with
ambulation and must report abnormal findings. Medication
, administration and specialized diabetic foot/nail care are
nursing responsibilities due to assessment and scope concerns.
Citation: Unit I: Aspects of Medical-Surgical Nursing (Chapter 1).
4. (Standard — Single best answer)
Lab values show rising BUN and creatinine over 24 hours
for a patient receiving multiple nephrotoxic agents. The
practical nurse should first:
A. Hold all scheduled oral medications.
B. Assess recent intake and output and urine
characteristics.
C. Prepare the patient for dialysis.
D. Increase oral fluids immediately.
Answer: B. Assess recent intake and output and urine
characteristics.
Rationale: Assessment of fluid balance and urine output is the
immediate nursing action to determine acute changes; holding
meds or starting treatments should follow assessment and
orders. Increasing fluids without assessing may be harmful.
Citation: Unit I: Aspects of Medical-Surgical Nursing (Chapter 1).
5. (Priority — First-action / Scenario)
A postoperative patient received IV morphine 30 minutes
ago and is now drowsy with a respiratory rate of 8
breaths/min and O₂ saturation 88%. What is the practical
