Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
Item 1
Reference: Ch. 1 — Clinical Judgment & the Nursing Process
(Overview)
Question Stem: A 67-year-old postoperative patient has new-
onset confusion and a temperature of 38.6°C. Which nursing
action is the highest priority?
A. Reorient the patient and provide a familiar object.
B. Notify the surgeon and prepare for possible imaging.
C. Assess respiratory status and obtain oxygen saturation.
D. Obtain blood and urine cultures and start antipyretic per
protocol.
Correct Answer: D
Rationales:
• D (Correct): New postoperative fever and confusion
suggest possible infection or sepsis; obtaining cultures and
initiating antipyretic (per protocol) supports timely
, diagnosis and treatment and aligns with early sepsis
recognition.
• A: Reorientation is appropriate but not the highest priority
when infection/sepsis is suspected.
• B: Notifying the surgeon is important but should follow
immediate diagnostics and initial interventions.
• C: Assessing respiratory status is needed if respiratory
compromise suspected, but current presentation
prioritizes infection workup.
Teaching Point: Early cultures and timely treatment are critical
for suspected postoperative infection.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Clinical Judgment & Nursing Process
Item 2
Reference: Ch. 1 — Prioritization & Safety Concepts
Question Stem: During morning rounds a nurse has four
assigned patients. Which patient should the nurse see first?
A. A patient scheduled for discharge after education completed
yesterday.
B. A patient reporting acute chest tightness and diaphoresis.
C. A patient requesting assistance with morning hygiene.
D. A patient due to receive an oral analgesic for chronic pain.
Correct Answer: B
,Rationales:
• B (Correct): Acute chest tightness and diaphoresis signal
possible myocardial ischemia — immediate assessment
and intervention are highest priority.
• A: Discharge is important but not urgent compared to
potential acute coronary syndrome.
• C: Hygiene assistance is lower priority than a patient with
possible life-threatening symptoms.
• D: Administering scheduled analgesics is important but not
before assessing the patient with chest symptoms.
Teaching Point: Prioritize patients with potential life-
threatening symptoms first.
Citation: Ignatavicius et al., 2024, Ch. 1: Prioritization & Safety
Item 3
Reference: Ch. 1 — Delegation & Supervision
Question Stem: The RN delegates morning vital signs to a
nursing assistant for a stable postoperative patient. Which task
must the RN retain responsibility for?
A. Asking the assistant to report the temperature only if >38°C.
B. Instructing the assistant to measure and report blood
pressure.
C. Interpreting the vital sign trends and modifying the plan of
care.
, D. Instructing the assistant to document readings in the
electronic record.
Correct Answer: C
Rationales:
• C (Correct): The RN retains responsibility for clinical
judgment, interpretation of data, and adjusting the plan of
care.
• A: Delegating report thresholds is acceptable, but the RN
still is responsible for decisions based on values.
• B: Measuring and reporting vitals can be delegated to
competent UAP.
• D: Documentation of measured values can be delegated,
though RN remains accountable for accuracy.
Teaching Point: RNs keep responsibility for interpreting data
and changing the care plan.
Citation: Ignatavicius et al., 2024, Ch. 1: Delegation &
Supervision
Item 4
Reference: Ch. 1 — Evidence-Based Practice & Quality
Improvement
Question Stem: A unit has rising central line–associated
bloodstream infections (CLABSIs). Which nursing-led action best
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
Item 1
Reference: Ch. 1 — Clinical Judgment & the Nursing Process
(Overview)
Question Stem: A 67-year-old postoperative patient has new-
onset confusion and a temperature of 38.6°C. Which nursing
action is the highest priority?
A. Reorient the patient and provide a familiar object.
B. Notify the surgeon and prepare for possible imaging.
C. Assess respiratory status and obtain oxygen saturation.
D. Obtain blood and urine cultures and start antipyretic per
protocol.
Correct Answer: D
Rationales:
• D (Correct): New postoperative fever and confusion
suggest possible infection or sepsis; obtaining cultures and
initiating antipyretic (per protocol) supports timely
, diagnosis and treatment and aligns with early sepsis
recognition.
• A: Reorientation is appropriate but not the highest priority
when infection/sepsis is suspected.
• B: Notifying the surgeon is important but should follow
immediate diagnostics and initial interventions.
• C: Assessing respiratory status is needed if respiratory
compromise suspected, but current presentation
prioritizes infection workup.
Teaching Point: Early cultures and timely treatment are critical
for suspected postoperative infection.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Clinical Judgment & Nursing Process
Item 2
Reference: Ch. 1 — Prioritization & Safety Concepts
Question Stem: During morning rounds a nurse has four
assigned patients. Which patient should the nurse see first?
A. A patient scheduled for discharge after education completed
yesterday.
B. A patient reporting acute chest tightness and diaphoresis.
C. A patient requesting assistance with morning hygiene.
D. A patient due to receive an oral analgesic for chronic pain.
Correct Answer: B
,Rationales:
• B (Correct): Acute chest tightness and diaphoresis signal
possible myocardial ischemia — immediate assessment
and intervention are highest priority.
• A: Discharge is important but not urgent compared to
potential acute coronary syndrome.
• C: Hygiene assistance is lower priority than a patient with
possible life-threatening symptoms.
• D: Administering scheduled analgesics is important but not
before assessing the patient with chest symptoms.
Teaching Point: Prioritize patients with potential life-
threatening symptoms first.
Citation: Ignatavicius et al., 2024, Ch. 1: Prioritization & Safety
Item 3
Reference: Ch. 1 — Delegation & Supervision
Question Stem: The RN delegates morning vital signs to a
nursing assistant for a stable postoperative patient. Which task
must the RN retain responsibility for?
A. Asking the assistant to report the temperature only if >38°C.
B. Instructing the assistant to measure and report blood
pressure.
C. Interpreting the vital sign trends and modifying the plan of
care.
, D. Instructing the assistant to document readings in the
electronic record.
Correct Answer: C
Rationales:
• C (Correct): The RN retains responsibility for clinical
judgment, interpretation of data, and adjusting the plan of
care.
• A: Delegating report thresholds is acceptable, but the RN
still is responsible for decisions based on values.
• B: Measuring and reporting vitals can be delegated to
competent UAP.
• D: Documentation of measured values can be delegated,
though RN remains accountable for accuracy.
Teaching Point: RNs keep responsibility for interpreting data
and changing the care plan.
Citation: Ignatavicius et al., 2024, Ch. 1: Delegation &
Supervision
Item 4
Reference: Ch. 1 — Evidence-Based Practice & Quality
Improvement
Question Stem: A unit has rising central line–associated
bloodstream infections (CLABSIs). Which nursing-led action best
