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 who had an
open appendectomy 10 hours ago reports increasing
shortness of breath and has an oxygen saturation of 88%
on room air, respirations 28/min, and diminished breath
sounds at the right base. Which nursing action should the
, PN perform first?
A. Encourage deep breathing and coughing and provide an
incentive spirometer.
B. Apply oxygen via nasal cannula at 2 L/min and reassess
breath sounds.
C. Notify the surgeon immediately for assessment.
D. Assist the client to sit upright and lean forward on an
overbed table.
Answer: B. Apply oxygen via nasal cannula at 2 L/min and
reassess breath sounds.
Rationale: The priority is to correct hypoxemia and stabilize
respiratory status. Applying oxygen is immediate, then reassess
to guide further interventions (positioning, cough, notify). This
reflects safety-first action for deteriorating oxygenation.
Source: Linton & Matteson, 1st ed. — Chapter 1: Aspects of
Medical-Surgical Nursing.
2. (Priority) A PN is caring for four clients on a med-surg unit.
Which client should the PN assess first?
A. A client 2 hours post-op with controlled pain and
dressing dry.
B. A client with newly reported chest pressure and
diaphoresis.
C. A client scheduled for discharge with stable vitals.
D. A client receiving IV antibiotics whose infusion is
completing now.
,Answer: B. A client with newly reported chest pressure and
diaphoresis.
Rationale: New chest pressure and diaphoresis suggest acute
coronary ischemia — immediate assessment and rapid
response are required. This is highest risk for deterioration.
Source: Linton & Matteson, 1st ed. — Chapter 1: Aspects of
Medical-Surgical Nursing.
3. (SATA) Which of the following tasks are appropriate to
delegate to a Licensed Practical Nurse/Registered Practical
Nurse (PN/LPN) within typical practical nursing scope for
stable med-surg clients? (Select all that apply.)
A. Administer scheduled oral medications to a stable
postoperative client.
B. Teach a newly diagnosed diabetic complex insulin pump
management.
C. Reinforce teaching about turning, coughing, and
incentive spirometry.
D. Initiate peripherally inserted central catheter (PICC)
insertion.
E. Monitor and report trends in urine output and skin
turgor.
Answer: A, C, E.
Rationale: PNs commonly administer routine meds, reinforce
patient teaching, and monitor/report trends. Complex initial
teaching (insulin pump) and invasive procedures (PICC
, insertion) are beyond typical PN scope and require RN/MD.
Delegation must match competence and scope.
Source: Linton & Matteson, 1st ed. — Chapter 1: Aspects of
Medical-Surgical Nursing.
4. (Scenario) A client with a history of COPD has an SpO₂ of
90% on 1 L O₂ by nasal cannula, RR 26, HR 110, and uses
accessory muscles. The PN notes the client looks anxious
and reports increased sputum. Which interpretation most
accurately guides the PN’s next step?
A. Hypoxemia is severe; prepare for immediate intubation.
B. Early respiratory compromise—assist to upright
position, encourage controlled breathing, suction if
needed, and notify RN/MD.
C. The oxygen saturation is acceptable for a COPD patient;
provide reassurance only.
D. Increase oxygen flow to 6 L/min via nonrebreather
immediately.
Answer: B. Early respiratory compromise—assist to upright
position, encourage controlled breathing, suction if needed,
and notify RN/MD.
Rationale: COPD clients may have lower baseline SpO₂; 90%
with accessory muscle use and tachypnea signals early
deterioration. Priority is noninvasive measures and prompt
escalation; intubation or high-flow O₂ may be unnecessary or
harmful without assessment. Notify RN/MD for further orders.
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 who had an
open appendectomy 10 hours ago reports increasing
shortness of breath and has an oxygen saturation of 88%
on room air, respirations 28/min, and diminished breath
sounds at the right base. Which nursing action should the
, PN perform first?
A. Encourage deep breathing and coughing and provide an
incentive spirometer.
B. Apply oxygen via nasal cannula at 2 L/min and reassess
breath sounds.
C. Notify the surgeon immediately for assessment.
D. Assist the client to sit upright and lean forward on an
overbed table.
Answer: B. Apply oxygen via nasal cannula at 2 L/min and
reassess breath sounds.
Rationale: The priority is to correct hypoxemia and stabilize
respiratory status. Applying oxygen is immediate, then reassess
to guide further interventions (positioning, cough, notify). This
reflects safety-first action for deteriorating oxygenation.
Source: Linton & Matteson, 1st ed. — Chapter 1: Aspects of
Medical-Surgical Nursing.
2. (Priority) A PN is caring for four clients on a med-surg unit.
Which client should the PN assess first?
A. A client 2 hours post-op with controlled pain and
dressing dry.
B. A client with newly reported chest pressure and
diaphoresis.
C. A client scheduled for discharge with stable vitals.
D. A client receiving IV antibiotics whose infusion is
completing now.
,Answer: B. A client with newly reported chest pressure and
diaphoresis.
Rationale: New chest pressure and diaphoresis suggest acute
coronary ischemia — immediate assessment and rapid
response are required. This is highest risk for deterioration.
Source: Linton & Matteson, 1st ed. — Chapter 1: Aspects of
Medical-Surgical Nursing.
3. (SATA) Which of the following tasks are appropriate to
delegate to a Licensed Practical Nurse/Registered Practical
Nurse (PN/LPN) within typical practical nursing scope for
stable med-surg clients? (Select all that apply.)
A. Administer scheduled oral medications to a stable
postoperative client.
B. Teach a newly diagnosed diabetic complex insulin pump
management.
C. Reinforce teaching about turning, coughing, and
incentive spirometry.
D. Initiate peripherally inserted central catheter (PICC)
insertion.
E. Monitor and report trends in urine output and skin
turgor.
Answer: A, C, E.
Rationale: PNs commonly administer routine meds, reinforce
patient teaching, and monitor/report trends. Complex initial
teaching (insulin pump) and invasive procedures (PICC
, insertion) are beyond typical PN scope and require RN/MD.
Delegation must match competence and scope.
Source: Linton & Matteson, 1st ed. — Chapter 1: Aspects of
Medical-Surgical Nursing.
4. (Scenario) A client with a history of COPD has an SpO₂ of
90% on 1 L O₂ by nasal cannula, RR 26, HR 110, and uses
accessory muscles. The PN notes the client looks anxious
and reports increased sputum. Which interpretation most
accurately guides the PN’s next step?
A. Hypoxemia is severe; prepare for immediate intubation.
B. Early respiratory compromise—assist to upright
position, encourage controlled breathing, suction if
needed, and notify RN/MD.
C. The oxygen saturation is acceptable for a COPD patient;
provide reassurance only.
D. Increase oxygen flow to 6 L/min via nonrebreather
immediately.
Answer: B. Early respiratory compromise—assist to upright
position, encourage controlled breathing, suction if needed,
and notify RN/MD.
Rationale: COPD clients may have lower baseline SpO₂; 90%
with accessory muscle use and tachypnea signals early
deterioration. Priority is noninvasive measures and prompt
escalation; intubation or high-flow O₂ may be unnecessary or
harmful without assessment. Notify RN/MD for further orders.
