Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
1
Reference
Ch. 1: Overview of Professional Nursing Concepts — Clinical
Judgment & Nursing Process
Question Stem
A 68-year-old post-op patient develops sudden shortness of
breath and tachycardia on the medical-surgical unit. Which
action should the nurse perform first using the nursing process
and clinical judgment?
Options
A. Administer PRN morphine for pain.
B. Assess breath sounds and oxygen saturation.
C. Notify the surgeon about the change in status.
D. Elevate the head of the bed to 90 degrees.
Correct Answer
B
,Rationales
• Correct (B): Assessing breath sounds and SpO₂ is the
immediate data-gathering step (assessment) required to
identify the cause of acute dyspnea and guide
interventions. Early assessment informs priority decisions.
• Incorrect (A): Administering morphine without assessment
may mask symptoms and delay diagnosis; pain is not the
most likely cause of acute dyspnea.
• Incorrect (C): Notifying the surgeon may be necessary but
is secondary to obtaining objective assessment data to
determine the urgency and appropriate intervention.
• Incorrect (D): Elevating the head may help but should
follow rapid assessment to confirm respiratory
compromise and guide oxygen therapy.
Teaching Point
Assessment (collecting objective data) guides immediate clinical
decisions and interventions.
Citation
Ignatavicius et al., 2024, Ch. 1: Clinical judgment and the
nursing process
2
Reference
Ch. 1: Patient Safety & Prioritization
,Question Stem
A nurse is caring for four patients. Which patient should the
nurse assess first based on the ABCs and Maslow-derived
prioritization?
Options
A. Postoperative patient 2 hours after surgery reporting
incisional pain 6/10.
B. Patient with dementia who is attempting to get out of bed
without a gait belt.
C. Patient with a new report of hematuria and suprapubic
cramping.
D. Patient on continuous heparin infusion with a platelet count
of 90,000/µL.
Correct Answer
D
Rationales
• Correct (D): A platelet count of 90,000 with ongoing
heparin raises immediate bleeding risk and requires urgent
assessment / possible infusion adjustment—
airway/breathing/circulation and safety priority.
• Incorrect (A): Post-op pain is important but less
immediately life-threatening than active bleeding risk.
• Incorrect (B): Fall risk requires prompt action (assist and
apply safety measures) but does not supersede a potential
bleeding complication.
, • Incorrect (C): Hematuria is concerning and should be
evaluated, but compared to thrombocytopenia with
anticoagulation, the bleeding-risk patient is higher priority.
Teaching Point
Prioritize patients by immediate threats to safety, perfusion,
and bleeding risk.
Citation
Ignatavicius et al., 2024, Ch. 1: Patient safety and prioritization
3
Reference
Ch. 1: Delegation & Scope of Practice
Question Stem
Which task is most appropriate for the RN to delegate to an
experienced LPN/LVN when caring for a stable medical-surgical
patient?
Options
A. Initial comprehensive admission assessment.
B. Administering a scheduled IM antibiotic.
C. Discharging teaching about wound care and return
precautions.
D. Interpreting new laboratory trend and adjusting IV
medications.
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
1
Reference
Ch. 1: Overview of Professional Nursing Concepts — Clinical
Judgment & Nursing Process
Question Stem
A 68-year-old post-op patient develops sudden shortness of
breath and tachycardia on the medical-surgical unit. Which
action should the nurse perform first using the nursing process
and clinical judgment?
Options
A. Administer PRN morphine for pain.
B. Assess breath sounds and oxygen saturation.
C. Notify the surgeon about the change in status.
D. Elevate the head of the bed to 90 degrees.
Correct Answer
B
,Rationales
• Correct (B): Assessing breath sounds and SpO₂ is the
immediate data-gathering step (assessment) required to
identify the cause of acute dyspnea and guide
interventions. Early assessment informs priority decisions.
• Incorrect (A): Administering morphine without assessment
may mask symptoms and delay diagnosis; pain is not the
most likely cause of acute dyspnea.
• Incorrect (C): Notifying the surgeon may be necessary but
is secondary to obtaining objective assessment data to
determine the urgency and appropriate intervention.
• Incorrect (D): Elevating the head may help but should
follow rapid assessment to confirm respiratory
compromise and guide oxygen therapy.
Teaching Point
Assessment (collecting objective data) guides immediate clinical
decisions and interventions.
Citation
Ignatavicius et al., 2024, Ch. 1: Clinical judgment and the
nursing process
2
Reference
Ch. 1: Patient Safety & Prioritization
,Question Stem
A nurse is caring for four patients. Which patient should the
nurse assess first based on the ABCs and Maslow-derived
prioritization?
Options
A. Postoperative patient 2 hours after surgery reporting
incisional pain 6/10.
B. Patient with dementia who is attempting to get out of bed
without a gait belt.
C. Patient with a new report of hematuria and suprapubic
cramping.
D. Patient on continuous heparin infusion with a platelet count
of 90,000/µL.
Correct Answer
D
Rationales
• Correct (D): A platelet count of 90,000 with ongoing
heparin raises immediate bleeding risk and requires urgent
assessment / possible infusion adjustment—
airway/breathing/circulation and safety priority.
• Incorrect (A): Post-op pain is important but less
immediately life-threatening than active bleeding risk.
• Incorrect (B): Fall risk requires prompt action (assist and
apply safety measures) but does not supersede a potential
bleeding complication.
, • Incorrect (C): Hematuria is concerning and should be
evaluated, but compared to thrombocytopenia with
anticoagulation, the bleeding-risk patient is higher priority.
Teaching Point
Prioritize patients by immediate threats to safety, perfusion,
and bleeding risk.
Citation
Ignatavicius et al., 2024, Ch. 1: Patient safety and prioritization
3
Reference
Ch. 1: Delegation & Scope of Practice
Question Stem
Which task is most appropriate for the RN to delegate to an
experienced LPN/LVN when caring for a stable medical-surgical
patient?
Options
A. Initial comprehensive admission assessment.
B. Administering a scheduled IM antibiotic.
C. Discharging teaching about wound care and return
precautions.
D. Interpreting new laboratory trend and adjusting IV
medications.
