Medical-Surgical Nursing: Concepts for
Clinical Judgment and Collaborative Care
11th Edition Test Bank | Donna D.
Ignatavicius, Cherie R. Rebar & Nicole M.
Heimgartner | Comprehensive Exam
Practice Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A nurse is caring for four clients. Which client should the nurse
assess first?
A. A client with chronic arthritis reporting pain of 6/10
B. A client with pneumonia who has an oxygen saturation of 88%
C. A client with diabetes requesting a snack
D. A client awaiting discharge instructions
Answer: B. A client with pneumonia who has an oxygen saturation
of 88%
An oxygen saturation of 88% indicates impaired oxygenation and
requires immediate assessment and intervention.
2. Which finding most strongly suggests acute respiratory distress?
A. Respiratory rate of 18/min
B. Oxygen saturation of 96%
C. Use of accessory muscles
D. Pink, warm skin
,Answer: C. Use of accessory muscles
Accessory muscle use indicates increased work of breathing and
possible respiratory compromise.
3. A hospitalized client suddenly becomes confused. What should the
nurse do first?
A. Administer a sedative
B. Assess oxygenation
C. Call the family
D. Apply restraints
Answer: B. Assess oxygenation
Acute confusion can result from hypoxemia. Airway and breathing
problems should be evaluated immediately.
4. Which assessment finding requires immediate intervention?
A. Temperature 37.4°C (99.3°F)
B. Heart rate 82/min
C. Blood pressure 118/72 mm Hg
D. New onset stridor
Answer: D. New onset stridor
Stridor indicates upper-airway obstruction and can rapidly become
life-threatening.
5. Which action best demonstrates clinical judgment?
A. Following every routine intervention without modification
B. Recognizing abnormal findings and determining their significance
,C. Delegating all assessments to assistive personnel
D. Waiting until the physician makes the diagnosis
Answer: B. Recognizing abnormal findings and determining their
significance
Clinical judgment involves recognizing cues, analyzing their meaning,
prioritizing hypotheses, and selecting appropriate actions.
6. Which client is at greatest risk for a pressure injury?
A. Ambulatory young adult
B. Client who independently changes position
C. Immobile client with poor nutritional intake
D. Client who walks three times daily
Answer: C. Immobile client with poor nutritional intake
Immobility and inadequate nutrition are major risk factors for
impaired tissue integrity.
7. Which intervention is most appropriate for preventing pressure
injuries?
A. Massage reddened bony prominences
B. Reposition the client regularly
C. Keep the skin continuously moist
D. Limit protein intake
Answer: B. Reposition the client regularly
Regular repositioning reduces prolonged pressure and supports tissue
perfusion.
8. A client is at high risk for falls. Which intervention is appropriate?
, A. Keep the bed in the highest position
B. Place frequently used items within reach
C. Keep all four side rails raised
D. Encourage the client to walk independently
Answer: B. Place frequently used items within reach
Keeping needed items accessible reduces unnecessary reaching and
ambulation.
9. Which assessment finding indicates possible hypovolemia?
A. Bounding pulse
B. Peripheral edema
C. Orthostatic hypotension
D. Jugular venous distention
Answer: C. Orthostatic hypotension
Orthostatic hypotension commonly occurs when circulating volume is
inadequate.
10. Which electrolyte abnormality can cause potentially dangerous
cardiac dysrhythmias?
A. Hyperkalemia
B. Mild hyperchloremia
C. Mild hyperphosphatemia
D. Mild hypernatremia
Answer: A. Hyperkalemia
Potassium abnormalities can significantly alter cardiac conduction
and may cause life-threatening dysrhythmias.
Clinical Judgment and Collaborative Care
11th Edition Test Bank | Donna D.
Ignatavicius, Cherie R. Rebar & Nicole M.
Heimgartner | Comprehensive Exam
Practice Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A nurse is caring for four clients. Which client should the nurse
assess first?
A. A client with chronic arthritis reporting pain of 6/10
B. A client with pneumonia who has an oxygen saturation of 88%
C. A client with diabetes requesting a snack
D. A client awaiting discharge instructions
Answer: B. A client with pneumonia who has an oxygen saturation
of 88%
An oxygen saturation of 88% indicates impaired oxygenation and
requires immediate assessment and intervention.
2. Which finding most strongly suggests acute respiratory distress?
A. Respiratory rate of 18/min
B. Oxygen saturation of 96%
C. Use of accessory muscles
D. Pink, warm skin
,Answer: C. Use of accessory muscles
Accessory muscle use indicates increased work of breathing and
possible respiratory compromise.
3. A hospitalized client suddenly becomes confused. What should the
nurse do first?
A. Administer a sedative
B. Assess oxygenation
C. Call the family
D. Apply restraints
Answer: B. Assess oxygenation
Acute confusion can result from hypoxemia. Airway and breathing
problems should be evaluated immediately.
4. Which assessment finding requires immediate intervention?
A. Temperature 37.4°C (99.3°F)
B. Heart rate 82/min
C. Blood pressure 118/72 mm Hg
D. New onset stridor
Answer: D. New onset stridor
Stridor indicates upper-airway obstruction and can rapidly become
life-threatening.
5. Which action best demonstrates clinical judgment?
A. Following every routine intervention without modification
B. Recognizing abnormal findings and determining their significance
,C. Delegating all assessments to assistive personnel
D. Waiting until the physician makes the diagnosis
Answer: B. Recognizing abnormal findings and determining their
significance
Clinical judgment involves recognizing cues, analyzing their meaning,
prioritizing hypotheses, and selecting appropriate actions.
6. Which client is at greatest risk for a pressure injury?
A. Ambulatory young adult
B. Client who independently changes position
C. Immobile client with poor nutritional intake
D. Client who walks three times daily
Answer: C. Immobile client with poor nutritional intake
Immobility and inadequate nutrition are major risk factors for
impaired tissue integrity.
7. Which intervention is most appropriate for preventing pressure
injuries?
A. Massage reddened bony prominences
B. Reposition the client regularly
C. Keep the skin continuously moist
D. Limit protein intake
Answer: B. Reposition the client regularly
Regular repositioning reduces prolonged pressure and supports tissue
perfusion.
8. A client is at high risk for falls. Which intervention is appropriate?
, A. Keep the bed in the highest position
B. Place frequently used items within reach
C. Keep all four side rails raised
D. Encourage the client to walk independently
Answer: B. Place frequently used items within reach
Keeping needed items accessible reduces unnecessary reaching and
ambulation.
9. Which assessment finding indicates possible hypovolemia?
A. Bounding pulse
B. Peripheral edema
C. Orthostatic hypotension
D. Jugular venous distention
Answer: C. Orthostatic hypotension
Orthostatic hypotension commonly occurs when circulating volume is
inadequate.
10. Which electrolyte abnormality can cause potentially dangerous
cardiac dysrhythmias?
A. Hyperkalemia
B. Mild hyperchloremia
C. Mild hyperphosphatemia
D. Mild hypernatremia
Answer: A. Hyperkalemia
Potassium abnormalities can significantly alter cardiac conduction
and may cause life-threatening dysrhythmias.
