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 68-year-old woman is admitted after a fall at home.
As the practical nurse begins the initial assessment,
which action best reflects the nurse’s primary
responsibility under the nursing process?
A. Teach the patient about fall precautions.
B. Perform a focused physical assessment to identify
injuries and immediate risks.
, C. Notify the family about the incident.
D. Complete incident reporting documentation.
Correct answer: B
Rationale: The first nursing responsibility is assessment to
identify immediate problems and safety risks; teaching and
documentation follow.
Citation: Linton & Matteson’s Medical-Surgical Practical
Nursing in Canada, 1st ed. — UNIT I: Medical-Surgical
Nursing — Aspects of Medical-Surgical Nursing
2. Which statement best describes the concept of clinical
judgment for the practical nurse in medical-surgical
care?
A. Relying solely on standardized protocols for all
patients.
B. Using critical thinking to interpret assessment data
and prioritize interventions.
C. Deferring all decision-making to the RN or
physician.
D. Memorizing diagnostic criteria for common
conditions.
Correct answer: B
Rationale: Clinical judgment integrates assessment,
interpretation, and prioritization to choose appropriate
interventions within scope.
,Citation: Linton & Matteson, 1st ed. — Aspects of Medical-
Surgical Nursing
3. Select all that apply. Which elements are essential
components of a thorough nursing assessment on
admission to a medical-surgical unit?
A. Current medications and allergies
B. Functional status and mobility level
C. Financial history and insurance details
D. Baseline vital signs and pain assessment
E. Detailed psychiatric history unrelated to current
problem
Correct answers: A, B, D
Rationale: Medication/allergies, function/mobility, and
baseline vitals/pain are high-yield for immediate care;
financial details and nonrelevant psychiatric history are not
essential for immediate nursing assessment.
Citation: Linton & Matteson, 1st ed. — Aspects of Medical-
Surgical Nursing
4. A patient with impaired mobility is placed on bedrest.
Which nursing intervention has the highest priority to
prevent complications of immobility?
A. Provide frequent oral hygiene.
B. Encourage incentive spirometry every 2 hours while
awake.
, C. Offer skin moisturizer each shift.
D. Teach range of motion exercises for the unaffected
limb only.
Correct answer: B
Rationale: Preventing respiratory complications
(atelectasis, pneumonia) via incentive spirometry is a high-
priority nursing action for immobile patients.
Citation: Linton & Matteson, 1st ed. — Aspects of Medical-
Surgical Nursing
5. Which action demonstrates appropriate delegation by
the practical nurse working with unregulated care
providers (UCPs)?
A. Delegating the initial assessment of a newly
admitted patient.
B. Asking the UCP to measure and record routine vital
signs for a stable patient.
C. Delegating medication administration to the UCP.
D. Assigning a UCP to develop the patient’s
individualized care plan.
Correct answer: B
Rationale: Delegation should match the UCP’s scope and
competence; routine stable vital signs are appropriate
tasks. Assessment, medication administration, and care
planning are not delegable.
Practical Nursing in Canada, 1st Edition
Authors:
Katherine Poser,Adrianne Dill Linton,Mary
Ann Matteson
TEST BANK.
1. A 68-year-old woman is admitted after a fall at home.
As the practical nurse begins the initial assessment,
which action best reflects the nurse’s primary
responsibility under the nursing process?
A. Teach the patient about fall precautions.
B. Perform a focused physical assessment to identify
injuries and immediate risks.
, C. Notify the family about the incident.
D. Complete incident reporting documentation.
Correct answer: B
Rationale: The first nursing responsibility is assessment to
identify immediate problems and safety risks; teaching and
documentation follow.
Citation: Linton & Matteson’s Medical-Surgical Practical
Nursing in Canada, 1st ed. — UNIT I: Medical-Surgical
Nursing — Aspects of Medical-Surgical Nursing
2. Which statement best describes the concept of clinical
judgment for the practical nurse in medical-surgical
care?
A. Relying solely on standardized protocols for all
patients.
B. Using critical thinking to interpret assessment data
and prioritize interventions.
C. Deferring all decision-making to the RN or
physician.
D. Memorizing diagnostic criteria for common
conditions.
Correct answer: B
Rationale: Clinical judgment integrates assessment,
interpretation, and prioritization to choose appropriate
interventions within scope.
,Citation: Linton & Matteson, 1st ed. — Aspects of Medical-
Surgical Nursing
3. Select all that apply. Which elements are essential
components of a thorough nursing assessment on
admission to a medical-surgical unit?
A. Current medications and allergies
B. Functional status and mobility level
C. Financial history and insurance details
D. Baseline vital signs and pain assessment
E. Detailed psychiatric history unrelated to current
problem
Correct answers: A, B, D
Rationale: Medication/allergies, function/mobility, and
baseline vitals/pain are high-yield for immediate care;
financial details and nonrelevant psychiatric history are not
essential for immediate nursing assessment.
Citation: Linton & Matteson, 1st ed. — Aspects of Medical-
Surgical Nursing
4. A patient with impaired mobility is placed on bedrest.
Which nursing intervention has the highest priority to
prevent complications of immobility?
A. Provide frequent oral hygiene.
B. Encourage incentive spirometry every 2 hours while
awake.
, C. Offer skin moisturizer each shift.
D. Teach range of motion exercises for the unaffected
limb only.
Correct answer: B
Rationale: Preventing respiratory complications
(atelectasis, pneumonia) via incentive spirometry is a high-
priority nursing action for immobile patients.
Citation: Linton & Matteson, 1st ed. — Aspects of Medical-
Surgical Nursing
5. Which action demonstrates appropriate delegation by
the practical nurse working with unregulated care
providers (UCPs)?
A. Delegating the initial assessment of a newly
admitted patient.
B. Asking the UCP to measure and record routine vital
signs for a stable patient.
C. Delegating medication administration to the UCP.
D. Assigning a UCP to develop the patient’s
individualized care plan.
Correct answer: B
Rationale: Delegation should match the UCP’s scope and
competence; routine stable vital signs are appropriate
tasks. Assessment, medication administration, and care
planning are not delegable.
