Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
1
Reference: Ch. 1: Clinical Judgment & the Nursing Process —
Nursing Assessment and Diagnosis
Question Stem: A 68-year-old postoperative patient on PCA
reports new confusion and decreased responsiveness. Which
nursing action is the priority?
A. Assess the PCA settings and recent opioid administration
times.
B. Document the neurological changes and notify the surgeon.
C. Reorient the patient and provide a familiar object from
home.
D. Call rapid response for immediate evaluation.
Correct Answer: D
Rationales:
• Correct (D): Sudden decreased responsiveness in a
postoperative patient may indicate respiratory depression
or other life-threatening complications; immediate rapid-
, response evaluation ensures timely stabilization. Rapid
response aligns with safety and escalation protocols.
• A: Assessing PCA is important but is secondary when a
patient shows potentially life-threatening decreased
responsiveness.
• B: Documentation and notifying the surgeon are necessary
but not the immediate life-saving step.
• C: Reorientation is appropriate for mild delirium, not for
acute decreased responsiveness.
Teaching Point: Immediately escalate care for sudden,
severe neurologic changes.
Citation: Ignatavicius et al., 2024, Ch. 1: Clinical Judgment
& Nursing Process
2
Reference: Ch. 1: Prioritization & Clinical Decision Making —
Safety and Patient Priorities
Question Stem: You are managing four med-surg patients.
Which patient should you assess first? (A) Postop total hip with
stable vitals, PCA working. (B) COPD patient with O₂ sat 88% on
2 L nasal cannula. (C) New admission with cellulitis, afebrile,
pain controlled. (D) Patient with urinary retention scheduled for
catheterization in 2 hours.
Correct Answer: B
Rationales:
, • Correct (B): An O₂ saturation of 88% indicates inadequate
oxygenation and immediate airway/respiratory assessment
is highest priority per ABCs.
• A: Postop stable patient is lower priority compared to
hypoxemia.
• C: Cellulitis patient can be managed after addressing acute
hypoxemia.
• D: Urinary retention scheduled later is not immediately
life-threatening.
Teaching Point: Prioritize airway/breathing when vital
signs indicate compromise.
Citation: Ignatavicius et al., 2024, Ch. 1: Prioritization &
Clinical Decision Making
3
Reference: Ch. 1: Delegation & Teamwork — Delegation
Principles
Question Stem: Which task is appropriate to delegate to an
experienced unlicensed assistive personnel (UAP) caring for a
stable med-surg patient?
A. Teach a newly diagnosed diabetic patient insulin injection
technique.
B. Assist the patient with morning hygiene and collect a routine
urine specimen.
C. Evaluate effectiveness of newly started pain medication.
, D. Perform a focused neurological assessment after a witnessed
fall.
Correct Answer: B
Rationales:
• Correct (B): UAPs can assist with ADLs and collect routine
specimens when patient is stable and tasks are within
facility/UAP scope.
• A: Teaching insulin requires RN assessment/education and
should not be delegated.
• C: Evaluating medication effectiveness requires clinical
judgment and RN responsibility.
• D: Neurological assessments after a fall require RN skill to
interpret subtle changes.
Teaching Point: Delegate only tasks within the delegatee’s
scope and facility policy.
Citation: Ignatavicius et al., 2024, Ch. 1: Delegation &
Teamwork
4
Reference: Ch. 1: Legal/Ethical Aspects — Informed Consent &
Delegation
Question Stem: A patient refuses a blood transfusion for
religious reasons but is now hypotensive and tachycardic from
GI bleed. What is the nurse’s best action?
A. Explain that transfusion is medically necessary and proceed
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
1
Reference: Ch. 1: Clinical Judgment & the Nursing Process —
Nursing Assessment and Diagnosis
Question Stem: A 68-year-old postoperative patient on PCA
reports new confusion and decreased responsiveness. Which
nursing action is the priority?
A. Assess the PCA settings and recent opioid administration
times.
B. Document the neurological changes and notify the surgeon.
C. Reorient the patient and provide a familiar object from
home.
D. Call rapid response for immediate evaluation.
Correct Answer: D
Rationales:
• Correct (D): Sudden decreased responsiveness in a
postoperative patient may indicate respiratory depression
or other life-threatening complications; immediate rapid-
, response evaluation ensures timely stabilization. Rapid
response aligns with safety and escalation protocols.
• A: Assessing PCA is important but is secondary when a
patient shows potentially life-threatening decreased
responsiveness.
• B: Documentation and notifying the surgeon are necessary
but not the immediate life-saving step.
• C: Reorientation is appropriate for mild delirium, not for
acute decreased responsiveness.
Teaching Point: Immediately escalate care for sudden,
severe neurologic changes.
Citation: Ignatavicius et al., 2024, Ch. 1: Clinical Judgment
& Nursing Process
2
Reference: Ch. 1: Prioritization & Clinical Decision Making —
Safety and Patient Priorities
Question Stem: You are managing four med-surg patients.
Which patient should you assess first? (A) Postop total hip with
stable vitals, PCA working. (B) COPD patient with O₂ sat 88% on
2 L nasal cannula. (C) New admission with cellulitis, afebrile,
pain controlled. (D) Patient with urinary retention scheduled for
catheterization in 2 hours.
Correct Answer: B
Rationales:
, • Correct (B): An O₂ saturation of 88% indicates inadequate
oxygenation and immediate airway/respiratory assessment
is highest priority per ABCs.
• A: Postop stable patient is lower priority compared to
hypoxemia.
• C: Cellulitis patient can be managed after addressing acute
hypoxemia.
• D: Urinary retention scheduled later is not immediately
life-threatening.
Teaching Point: Prioritize airway/breathing when vital
signs indicate compromise.
Citation: Ignatavicius et al., 2024, Ch. 1: Prioritization &
Clinical Decision Making
3
Reference: Ch. 1: Delegation & Teamwork — Delegation
Principles
Question Stem: Which task is appropriate to delegate to an
experienced unlicensed assistive personnel (UAP) caring for a
stable med-surg patient?
A. Teach a newly diagnosed diabetic patient insulin injection
technique.
B. Assist the patient with morning hygiene and collect a routine
urine specimen.
C. Evaluate effectiveness of newly started pain medication.
, D. Perform a focused neurological assessment after a witnessed
fall.
Correct Answer: B
Rationales:
• Correct (B): UAPs can assist with ADLs and collect routine
specimens when patient is stable and tasks are within
facility/UAP scope.
• A: Teaching insulin requires RN assessment/education and
should not be delegated.
• C: Evaluating medication effectiveness requires clinical
judgment and RN responsibility.
• D: Neurological assessments after a fall require RN skill to
interpret subtle changes.
Teaching Point: Delegate only tasks within the delegatee’s
scope and facility policy.
Citation: Ignatavicius et al., 2024, Ch. 1: Delegation &
Teamwork
4
Reference: Ch. 1: Legal/Ethical Aspects — Informed Consent &
Delegation
Question Stem: A patient refuses a blood transfusion for
religious reasons but is now hypotensive and tachycardic from
GI bleed. What is the nurse’s best action?
A. Explain that transfusion is medically necessary and proceed
