Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius;
Cherie R. Rebar; Nicole M.
Heimgartner
• Publisher Published by Elsevier
UK Copyright© 2024
• Print ISBN: 9780323878265
TEST BANK
,Question 1
A nurse is caring for four clients on a medical-surgical unit.
Which client should the nurse assess first?
A. A client reporting new-onset shortness of breath and
restlessness
B. A client requesting assistance to the bathroom
C. A client asking questions about discharge instructions
D. A client reporting mild postoperative incisional pain
Correct Answer: A
Rationale:
The client with new-onset shortness of breath and restlessness
may be experiencing impaired oxygenation and requires
immediate assessment. Airway and breathing concerns take
priority over comfort, teaching, and routine care needs. The
other clients have needs that are important but not
immediately life-threatening.
Source:
Medical-Surgical Nursing, 8th Edition — Unit I: Aspects of
Medical-Surgical Nursing
Question 2
,A nurse receives a prescription that appears unclear and
potentially unsafe. What is the nurse's priority action?
A. Administer the medication as written
B. Ask another nurse to interpret the prescription
C. Clarify the prescription with the healthcare provider
D. Delay the medication until the next shift
Correct Answer: C
Rationale:
The nurse has a legal and ethical responsibility to clarify unclear
prescriptions before implementation. Administering an unclear
order may jeopardize client safety. Another nurse cannot
authorize interpretation of an ambiguous prescription. Delaying
care without attempting clarification is inappropriate.
Source:
Medical-Surgical Nursing, 8th Edition — Unit I: Aspects of
Medical-Surgical Nursing
Question 3
NGN Case Scenario
A nurse notices that a client appears anxious, is breathing
rapidly, and states, "I don't feel right."
Which assessment findings support the need for immediate
intervention? Select all that apply.
, A. Oxygen saturation of 86%
B. Respiratory rate of 32/min
C. Warm, dry skin
D. Difficulty speaking in complete sentences
E. Heart rate of 124/min
Correct Answer: A, B, D, E
Rationale:
Low oxygen saturation, tachypnea, inability to speak in
complete sentences, and tachycardia are signs of possible
respiratory compromise requiring prompt intervention. Warm,
dry skin alone does not indicate immediate deterioration.
Source:
Medical-Surgical Nursing, 8th Edition — Unit I: Aspects of
Medical-Surgical Nursing
Question 4
A nurse manager is assigning tasks to personnel. Which task is
most appropriate to delegate to unlicensed assistive personnel
(UAP)?
A. Assess a client's pain level
B. Develop a nursing care plan
C. Obtain routine vital signs on a stable client
D. Evaluate a client's response to medication
Correct Answer: C
11th Edition
• Author(s)Donna D. Ignatavicius;
Cherie R. Rebar; Nicole M.
Heimgartner
• Publisher Published by Elsevier
UK Copyright© 2024
• Print ISBN: 9780323878265
TEST BANK
,Question 1
A nurse is caring for four clients on a medical-surgical unit.
Which client should the nurse assess first?
A. A client reporting new-onset shortness of breath and
restlessness
B. A client requesting assistance to the bathroom
C. A client asking questions about discharge instructions
D. A client reporting mild postoperative incisional pain
Correct Answer: A
Rationale:
The client with new-onset shortness of breath and restlessness
may be experiencing impaired oxygenation and requires
immediate assessment. Airway and breathing concerns take
priority over comfort, teaching, and routine care needs. The
other clients have needs that are important but not
immediately life-threatening.
Source:
Medical-Surgical Nursing, 8th Edition — Unit I: Aspects of
Medical-Surgical Nursing
Question 2
,A nurse receives a prescription that appears unclear and
potentially unsafe. What is the nurse's priority action?
A. Administer the medication as written
B. Ask another nurse to interpret the prescription
C. Clarify the prescription with the healthcare provider
D. Delay the medication until the next shift
Correct Answer: C
Rationale:
The nurse has a legal and ethical responsibility to clarify unclear
prescriptions before implementation. Administering an unclear
order may jeopardize client safety. Another nurse cannot
authorize interpretation of an ambiguous prescription. Delaying
care without attempting clarification is inappropriate.
Source:
Medical-Surgical Nursing, 8th Edition — Unit I: Aspects of
Medical-Surgical Nursing
Question 3
NGN Case Scenario
A nurse notices that a client appears anxious, is breathing
rapidly, and states, "I don't feel right."
Which assessment findings support the need for immediate
intervention? Select all that apply.
, A. Oxygen saturation of 86%
B. Respiratory rate of 32/min
C. Warm, dry skin
D. Difficulty speaking in complete sentences
E. Heart rate of 124/min
Correct Answer: A, B, D, E
Rationale:
Low oxygen saturation, tachypnea, inability to speak in
complete sentences, and tachycardia are signs of possible
respiratory compromise requiring prompt intervention. Warm,
dry skin alone does not indicate immediate deterioration.
Source:
Medical-Surgical Nursing, 8th Edition — Unit I: Aspects of
Medical-Surgical Nursing
Question 4
A nurse manager is assigning tasks to personnel. Which task is
most appropriate to delegate to unlicensed assistive personnel
(UAP)?
A. Assess a client's pain level
B. Develop a nursing care plan
C. Obtain routine vital signs on a stable client
D. Evaluate a client's response to medication
Correct Answer: C
