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. Item Type: Standard (single-best-answer)
A 78-year-old patient on the medical unit has a new order
for daily oral acetaminophen PRN for mild pain. The
patient’s daughter asks you, the PN, whether she can give
, the patient extra acetaminophen from home because staff
"only gives it once a day." Which response by the PN is
most appropriate?
A. “Yes — if it’s the same acetaminophen we give here you
may bring it and give it.”
B. “No — personal medications are never allowed on the
unit.”
C. “I can’t accept or administer medication from home; I’ll
notify the RN to clarify and, if appropriate, the home
medication can be sent to Pharmacy for reconciliation.”
D. “Let me give the acetaminophen now and you can bring
the rest later.”
Answer: C
Rationale: Medication safety, reconciliation, and scope: PNs
must follow facility policy and not independently
accept/administer home meds without reconciliation and
RN/pharmacy involvement. This protects against
duplication/interaction and follows safe medication
administration and reporting responsibilities.
2. Item Type: Priority (first-action)
During change-of-shift report you receive a brief handover:
“Mr. B — postop 6 hrs, PCA off at 0400 for low respiratory
rate, SpO₂ 88% on room air at 0500, given oxygen 2 L by
nasal cannula, now sleepy but arousable.” What is the PN’s
priority immediate action?
, A. Document the report and monitor hourly.
B. Assess respiratory rate, work of breathing, and oxygen
saturation now.
C. Call the surgeon for postoperative orders.
D. Increase oxygen to 4 L and notify the RN.
Answer: B
Rationale: Immediate bedside assessment is required to
evaluate current respiratory status and determine
deterioration. Prioritize direct assessment (airway/ breathing)
before delegating or escalating. Findings will dictate further
actions (RN notification, oxygen titration, possible opioid
reversal).
3. Item Type: SATA
Which of the following actions are appropriate for a PN
working within Canadian PN/LPN scope when delegating
tasks to unregulated care providers (UCPs)? (Select all that
apply.)
A. Delegate a stable patient’s routine oral hygiene with
explicit steps and expected outcome.
B. Assign a UCP to administer subcutaneous insulin
boluses.
C. Provide clear instructions including how and when to
report unexpected findings.
D. Ensure the delegated task matches the UCP’s
competencies and facility policy.
, E. Delegate assessment of wound infection and
interpretation to a UCP.
Answer: A, C, D
Rationale: PNs may delegate stable, routine tasks that match
competence and policy, provide clear instructions and reporting
expectations. Delegation of medication administration and
clinical assessment/interpretation is outside typical UCP role
and requires RN/PN assessment per scope.
4. Item Type: Scenario (clinical judgment)
A patient with CHF has trending weights: 0700 today 68.5
kg (baseline 66.0 kg two days ago). The patient reports
increased dyspnea when ambulating. Vitals: HR 102, BP
138/84, RR 24, SpO₂ 90% on 2 L. Which nursing action
should the PN perform first?
A. Notify the RN/physician immediately about weight gain
and respiratory changes.
B. Encourage the patient to ambulate more to reduce fluid
retention.
C. Review I/O and scheduled diuretics and reassess lung
sounds and peripheral edema.
D. Restrict oral fluids for the remainder of shift.
Answer: C
Rationale: First, gather focused data (I/O, diuretics timing, lung
sounds, edema) to clarify deterioration and inform escalation.
This step-driven assessment guides appropriate reporting and
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. Item Type: Standard (single-best-answer)
A 78-year-old patient on the medical unit has a new order
for daily oral acetaminophen PRN for mild pain. The
patient’s daughter asks you, the PN, whether she can give
, the patient extra acetaminophen from home because staff
"only gives it once a day." Which response by the PN is
most appropriate?
A. “Yes — if it’s the same acetaminophen we give here you
may bring it and give it.”
B. “No — personal medications are never allowed on the
unit.”
C. “I can’t accept or administer medication from home; I’ll
notify the RN to clarify and, if appropriate, the home
medication can be sent to Pharmacy for reconciliation.”
D. “Let me give the acetaminophen now and you can bring
the rest later.”
Answer: C
Rationale: Medication safety, reconciliation, and scope: PNs
must follow facility policy and not independently
accept/administer home meds without reconciliation and
RN/pharmacy involvement. This protects against
duplication/interaction and follows safe medication
administration and reporting responsibilities.
2. Item Type: Priority (first-action)
During change-of-shift report you receive a brief handover:
“Mr. B — postop 6 hrs, PCA off at 0400 for low respiratory
rate, SpO₂ 88% on room air at 0500, given oxygen 2 L by
nasal cannula, now sleepy but arousable.” What is the PN’s
priority immediate action?
, A. Document the report and monitor hourly.
B. Assess respiratory rate, work of breathing, and oxygen
saturation now.
C. Call the surgeon for postoperative orders.
D. Increase oxygen to 4 L and notify the RN.
Answer: B
Rationale: Immediate bedside assessment is required to
evaluate current respiratory status and determine
deterioration. Prioritize direct assessment (airway/ breathing)
before delegating or escalating. Findings will dictate further
actions (RN notification, oxygen titration, possible opioid
reversal).
3. Item Type: SATA
Which of the following actions are appropriate for a PN
working within Canadian PN/LPN scope when delegating
tasks to unregulated care providers (UCPs)? (Select all that
apply.)
A. Delegate a stable patient’s routine oral hygiene with
explicit steps and expected outcome.
B. Assign a UCP to administer subcutaneous insulin
boluses.
C. Provide clear instructions including how and when to
report unexpected findings.
D. Ensure the delegated task matches the UCP’s
competencies and facility policy.
, E. Delegate assessment of wound infection and
interpretation to a UCP.
Answer: A, C, D
Rationale: PNs may delegate stable, routine tasks that match
competence and policy, provide clear instructions and reporting
expectations. Delegation of medication administration and
clinical assessment/interpretation is outside typical UCP role
and requires RN/PN assessment per scope.
4. Item Type: Scenario (clinical judgment)
A patient with CHF has trending weights: 0700 today 68.5
kg (baseline 66.0 kg two days ago). The patient reports
increased dyspnea when ambulating. Vitals: HR 102, BP
138/84, RR 24, SpO₂ 90% on 2 L. Which nursing action
should the PN perform first?
A. Notify the RN/physician immediately about weight gain
and respiratory changes.
B. Encourage the patient to ambulate more to reduce fluid
retention.
C. Review I/O and scheduled diuretics and reassess lung
sounds and peripheral edema.
D. Restrict oral fluids for the remainder of shift.
Answer: C
Rationale: First, gather focused data (I/O, diuretics timing, lung
sounds, edema) to clarify deterioration and inform escalation.
This step-driven assessment guides appropriate reporting and
