MEDICAL-SURGICAL NURSING 11TH EDITION TEST
BANK – IGNATAVICIUS, REBAR & HEIMGARTNER,
CLINICAL JUDGMENT & COLLABORATIVE CARE,
ISBN 978-0323878265
SECTION 1: FOUNDATIONS OF MEDICAL-SURGICAL NURSING (Questions 1-30)
1. A nurse is assessing the effect of a client's cultural background on their health care
practices. Which competency is the nurse demonstrating?
A. Evidence-based practice
B. Client-focused care
C. Interprofessional collaboration
D. Quality improvement
Answer: B
Rationale: Client-focused care is demonstrated when the nurse focuses on
communication, culture, respect, compassion, client education, and empowerment. By
assessing the effect of the client's culture on health care, this nurse is practicing client-
focused care. Evidence-based practice involves integrating best evidence with clinical
expertise. Interprofessional collaboration involves working with other health care
professionals. Quality improvement focuses on systematic processes to improve patient
outcomes .
,2. The nurse is prioritizing care for four patients on a medical-surgical unit. Which
patient should the nurse assess first?
A. A patient with diabetes who has a blood glucose of 150 mg/dL
B. A patient with pneumonia who has a pulse oximetry reading of 92%
C. A patient with heart failure who reports shortness of breath and has a respiratory rate of
28 breaths per minute
D. A patient with chronic kidney disease who has a potassium level of 5.2 mEq/L
Answer: C
Rationale: Prioritization is based on the ABCs (Airway, Breathing, Circulation) and the
potential for life-threatening complications. The patient with heart failure and shortness of
breath with tachypnea (RR 28) is demonstrating acute respiratory distress and requires
immediate assessment and intervention. A pulse oximetry of 92% in a pneumonia patient
is concerning but stable. A blood glucose of 150 mg/dL is slightly elevated but not
immediately dangerous. A potassium of 5.2 mEq/L is mildly elevated and requires
monitoring but is not the priority over respiratory distress .
3. Which task is most appropriate for the RN to delegate to an experienced LPN/LVN
when caring for a stable medical-surgical patient?
A. Initial comprehensive admission assessment
B. Administering a scheduled IM antibiotic
C. Discharge teaching about wound care and return precautions
D. Interpreting new laboratory trends and adjusting IV medications
Answer: B
Rationale: Medication administration, including scheduled IM antibiotics for a stable
patient, is within the scope of practice for many LPN/LVNs with appropriate training and
supervision. Delegation is appropriate for stable, routine tasks. Initial comprehensive
assessment requires RN judgment and cannot be delegated. Discharge teaching involves
complex teaching and evaluation—an RN responsibility. Interpreting labs and adjusting IV
meds involve complex clinical judgment and are RN responsibilities .
4. A patient with COPD on the medical-surgical unit becomes more lethargic and has a
respiratory rate of 8 breaths per minute after receiving a PRN opioid. Using clinical
judgment, what is the nurse's best immediate action?
,A. Encourage pursed-lip breathing
B. Stimulate the patient and prepare to administer naloxone per protocol
C. Offer supplemental oxygen via nasal cannula at 2 L/min
D. Document findings and reassess in 30 minutes
Answer: B
Rationale: Lethargy and a respiratory rate of 8 breaths per minute after opioid
administration suggest opioid-induced respiratory depression. Stimulating the patient and
preparing to administer naloxone per protocol is the immediate, potentially life-saving
action. Pursed-lip breathing is not effective for opioid-induced respiratory depression and
may delay reversal. Oxygen alone may not correct hypoventilation from opioids and could
mask hypoventilation. Waiting would risk further respiratory compromise .
5. A competent adult patient with end-stage illness refuses a life-sustaining
treatment. The nurse disagrees with the patient's decision. What is the nurse's most
appropriate action?
A. Continue to persuade the patient to accept the treatment
B. Respect the patient's decision and document the refusal
C. Contact the hospital ethics committee immediately
D. Ask the family to convince the patient to accept the treatment
Answer: B
Rationale: Respecting patient autonomy is a fundamental ethical principle in nursing. A
competent adult has the right to refuse treatment, even if the healthcare team disagrees.
The nurse should respect the decision, document the refusal clearly, and collaborate with
the healthcare team to explore alternatives. Continuing to persuade the patient
undermines autonomy. Contacting the ethics committee may be appropriate for complex
dilemmas but is not the first action for a clear refusal by a competent patient .
6. After administering a morning dose, a nurse realizes they gave the wrong medication
to a stable patient. What is the nurse's first appropriate action?
A. Wait and see if the patient has adverse effects before reporting
B. Notify the provider and follow the facility's incident-reporting procedure
C. Destroy the medication to avoid detection
D. Tell the patient it was the correct medication and continue rounds
, Answer: B
Rationale: Immediate notification of the provider and following incident-reporting
processes ensures patient safety, prompt monitoring, and system-level learning. Waiting
delays interventions and risks harm. Concealment is unethical and unsafe. Misleading the
patient denies informed monitoring and is unethical .
7. A nurse is giving change-of-shift report using SBAR for a patient with a recent chest
tube. Which statement correctly conveys the recommendation?
A. Situation: "Patient is doing well with no issues."
B. Background: "The patient had a pneumothorax and a chest tube was placed 2 days ago."
C. Assessment: "I recommend the provider be notified about the patient's increased
oxygen requirement."
D. Recommendation: "I recommend the provider be notified about the patient's increased
oxygen requirement."
Answer: D
Rationale: SBAR (Situation, Background, Assessment, Recommendation) is a standardized
communication tool. The Recommendation component should clearly state what the
nurse suggests should happen next. Option D correctly identifies this as the
recommendation. Situation should be a concise statement of the current problem.
Background should provide relevant context. Assessment should include the nurse's
professional assessment of the situation .
8. A patient who had major abdominal surgery 3 days ago develops a fever,
tachycardia, and hypotension. The nurse assesses the surgical wound and notes
purulent drainage with a foul odor. Which action should the nurse take first?
A. Obtain a wound culture
B. Administer prescribed antibiotics
C. Notify the healthcare provider
D. Assess the patient's oxygen saturation
Answer: D
Rationale: The ABCs (Airway, Breathing, Circulation) are always the priority. The patient is
showing signs of sepsis, but the nurse must first assess the patient's oxygenation and
hemodynamic status. Airway and breathing take priority over the wound infection. After
BANK – IGNATAVICIUS, REBAR & HEIMGARTNER,
CLINICAL JUDGMENT & COLLABORATIVE CARE,
ISBN 978-0323878265
SECTION 1: FOUNDATIONS OF MEDICAL-SURGICAL NURSING (Questions 1-30)
1. A nurse is assessing the effect of a client's cultural background on their health care
practices. Which competency is the nurse demonstrating?
A. Evidence-based practice
B. Client-focused care
C. Interprofessional collaboration
D. Quality improvement
Answer: B
Rationale: Client-focused care is demonstrated when the nurse focuses on
communication, culture, respect, compassion, client education, and empowerment. By
assessing the effect of the client's culture on health care, this nurse is practicing client-
focused care. Evidence-based practice involves integrating best evidence with clinical
expertise. Interprofessional collaboration involves working with other health care
professionals. Quality improvement focuses on systematic processes to improve patient
outcomes .
,2. The nurse is prioritizing care for four patients on a medical-surgical unit. Which
patient should the nurse assess first?
A. A patient with diabetes who has a blood glucose of 150 mg/dL
B. A patient with pneumonia who has a pulse oximetry reading of 92%
C. A patient with heart failure who reports shortness of breath and has a respiratory rate of
28 breaths per minute
D. A patient with chronic kidney disease who has a potassium level of 5.2 mEq/L
Answer: C
Rationale: Prioritization is based on the ABCs (Airway, Breathing, Circulation) and the
potential for life-threatening complications. The patient with heart failure and shortness of
breath with tachypnea (RR 28) is demonstrating acute respiratory distress and requires
immediate assessment and intervention. A pulse oximetry of 92% in a pneumonia patient
is concerning but stable. A blood glucose of 150 mg/dL is slightly elevated but not
immediately dangerous. A potassium of 5.2 mEq/L is mildly elevated and requires
monitoring but is not the priority over respiratory distress .
3. Which task is most appropriate for the RN to delegate to an experienced LPN/LVN
when caring for a stable medical-surgical patient?
A. Initial comprehensive admission assessment
B. Administering a scheduled IM antibiotic
C. Discharge teaching about wound care and return precautions
D. Interpreting new laboratory trends and adjusting IV medications
Answer: B
Rationale: Medication administration, including scheduled IM antibiotics for a stable
patient, is within the scope of practice for many LPN/LVNs with appropriate training and
supervision. Delegation is appropriate for stable, routine tasks. Initial comprehensive
assessment requires RN judgment and cannot be delegated. Discharge teaching involves
complex teaching and evaluation—an RN responsibility. Interpreting labs and adjusting IV
meds involve complex clinical judgment and are RN responsibilities .
4. A patient with COPD on the medical-surgical unit becomes more lethargic and has a
respiratory rate of 8 breaths per minute after receiving a PRN opioid. Using clinical
judgment, what is the nurse's best immediate action?
,A. Encourage pursed-lip breathing
B. Stimulate the patient and prepare to administer naloxone per protocol
C. Offer supplemental oxygen via nasal cannula at 2 L/min
D. Document findings and reassess in 30 minutes
Answer: B
Rationale: Lethargy and a respiratory rate of 8 breaths per minute after opioid
administration suggest opioid-induced respiratory depression. Stimulating the patient and
preparing to administer naloxone per protocol is the immediate, potentially life-saving
action. Pursed-lip breathing is not effective for opioid-induced respiratory depression and
may delay reversal. Oxygen alone may not correct hypoventilation from opioids and could
mask hypoventilation. Waiting would risk further respiratory compromise .
5. A competent adult patient with end-stage illness refuses a life-sustaining
treatment. The nurse disagrees with the patient's decision. What is the nurse's most
appropriate action?
A. Continue to persuade the patient to accept the treatment
B. Respect the patient's decision and document the refusal
C. Contact the hospital ethics committee immediately
D. Ask the family to convince the patient to accept the treatment
Answer: B
Rationale: Respecting patient autonomy is a fundamental ethical principle in nursing. A
competent adult has the right to refuse treatment, even if the healthcare team disagrees.
The nurse should respect the decision, document the refusal clearly, and collaborate with
the healthcare team to explore alternatives. Continuing to persuade the patient
undermines autonomy. Contacting the ethics committee may be appropriate for complex
dilemmas but is not the first action for a clear refusal by a competent patient .
6. After administering a morning dose, a nurse realizes they gave the wrong medication
to a stable patient. What is the nurse's first appropriate action?
A. Wait and see if the patient has adverse effects before reporting
B. Notify the provider and follow the facility's incident-reporting procedure
C. Destroy the medication to avoid detection
D. Tell the patient it was the correct medication and continue rounds
, Answer: B
Rationale: Immediate notification of the provider and following incident-reporting
processes ensures patient safety, prompt monitoring, and system-level learning. Waiting
delays interventions and risks harm. Concealment is unethical and unsafe. Misleading the
patient denies informed monitoring and is unethical .
7. A nurse is giving change-of-shift report using SBAR for a patient with a recent chest
tube. Which statement correctly conveys the recommendation?
A. Situation: "Patient is doing well with no issues."
B. Background: "The patient had a pneumothorax and a chest tube was placed 2 days ago."
C. Assessment: "I recommend the provider be notified about the patient's increased
oxygen requirement."
D. Recommendation: "I recommend the provider be notified about the patient's increased
oxygen requirement."
Answer: D
Rationale: SBAR (Situation, Background, Assessment, Recommendation) is a standardized
communication tool. The Recommendation component should clearly state what the
nurse suggests should happen next. Option D correctly identifies this as the
recommendation. Situation should be a concise statement of the current problem.
Background should provide relevant context. Assessment should include the nurse's
professional assessment of the situation .
8. A patient who had major abdominal surgery 3 days ago develops a fever,
tachycardia, and hypotension. The nurse assesses the surgical wound and notes
purulent drainage with a foul odor. Which action should the nurse take first?
A. Obtain a wound culture
B. Administer prescribed antibiotics
C. Notify the healthcare provider
D. Assess the patient's oxygen saturation
Answer: D
Rationale: The ABCs (Airway, Breathing, Circulation) are always the priority. The patient is
showing signs of sepsis, but the nurse must first assess the patient's oxygenation and
hemodynamic status. Airway and breathing take priority over the wound infection. After
