Medical-Surgical Nursing: Concepts for Interprofessional
Collaborative Care (11th Ed.) — Unit I (Ch. 1–9).
Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
Reference: Ch. 2: Clinical Judgment and Systems Thinking —
Recognizing Cues & Prioritization
Question Stem: A 68-year-old postop patient with COPD
becomes increasingly restless and reports shortness of breath;
SpO₂ is 88% on room air and respiratory rate is 28. Using clinical
judgment, which action should the nurse take first?
A. Encourage the patient to use pursed-lip breathing.
B. Apply supplemental oxygen per protocol and reassess.
C. Call the respiratory therapist to evaluate and schedule
inhaled bronchodilator therapy.
D. Sit the patient upright and ambulate to improve ventilation.
Correct Answer: B
Rationales:
• Correct (B): Hypoxemia (SpO₂ 88%) is an immediate safety
cue; applying oxygen per protocol is the highest priority to
correct oxygenation while reassessing. This follows
, recognizing cues → take action in the clinical judgment
cycle.
• A: Pursed-lip breathing can help COPD patients but is
lower priority when oxygenation is inadequate.
• C: Respiratory therapy consult is appropriate but delays
immediate correction of hypoxemia.
• D: Upright positioning may help ventilation but ambulation
when SpO₂ is 88% and RR 28 is unsafe before oxygenation
is improved.
Teaching Point: Correct hypoxemia immediately; reassess and
then escalate care.
Citation: Ignatavicius et al., 2023, Ch. 2: Recognizing Cues and
Taking Action
2
Reference: Ch. 1: Overview of Professional Nursing Concepts —
Safety & Teamwork/Delegation
Question Stem: A newly licensed nurse on a med–surg unit is
managing four patients. Which task is most appropriate to
delegate to an experienced unlicensed assistive personnel
(UAP)?
A. Obtain capillary glucose for an insulin-dependent patient
scheduled for surgery.
B. Reinforce teaching about incentive spirometer use to a
,postop patient.
C. Assist a stable postoperative patient from bed to bedside
chair using a transfer belt.
D. Administer oral antibiotics to a patient with community-
acquired pneumonia.
Correct Answer: C
Rationales:
• Correct (C): Ambulation/assistance with transfers for a
stable patient is within UAP scope when trained;
delegation requires stable patient and clear instructions.
• A: Capillary glucose may be delegated in some settings, but
an insulin-dependent patient preop requires RN judgment
and documentation in many policies.
• B: Reinforcement of teaching often requires clinical
judgment and assessment of learning—RN responsibility.
• D: Medication administration is an RN role and should not
be delegated to UAP.
Teaching Point: Delegate stable, routine ADLs to trained UAPs;
keep assessments and meds for RNs.
Citation: Ignatavicius et al., 2023, Ch. 1: Teamwork, Delegation,
and Safety
3
, Reference: Ch. 3: Overview of Health Concepts — Homeostasis,
Inflammation, and Infection Control
Question Stem: A patient with an infected foot wound has a
temperature of 38.9°C, tachycardia, and leukocytosis. Which
nursing intervention best reflects understanding of systemic
inflammatory response and infection control?
A. Obtain wound culture before administering the first dose of
antibiotics.
B. Place the patient in protective isolation to prevent acquiring
other infections.
C. Begin antipyretic therapy and schedule a CT scan
immediately.
D. Teach family about using alcohol-based hand rubs at home.
Correct Answer: A
Rationales:
• Correct (A): Obtaining cultures prior to antibiotics
maximizes diagnostic yield and guides targeted therapy —
consistent with infection management and antimicrobial
stewardship.
• B: Protective isolation is for immunocompromised
patients; this patient is infectious, so standard + contact
precautions as indicated are appropriate.
• C: Antipyretics are supportive but cultures guide therapy;
CT is not first-line unless deep tissue involvement
suspected.
Collaborative Care (11th Ed.) — Unit I (Ch. 1–9).
Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
Reference: Ch. 2: Clinical Judgment and Systems Thinking —
Recognizing Cues & Prioritization
Question Stem: A 68-year-old postop patient with COPD
becomes increasingly restless and reports shortness of breath;
SpO₂ is 88% on room air and respiratory rate is 28. Using clinical
judgment, which action should the nurse take first?
A. Encourage the patient to use pursed-lip breathing.
B. Apply supplemental oxygen per protocol and reassess.
C. Call the respiratory therapist to evaluate and schedule
inhaled bronchodilator therapy.
D. Sit the patient upright and ambulate to improve ventilation.
Correct Answer: B
Rationales:
• Correct (B): Hypoxemia (SpO₂ 88%) is an immediate safety
cue; applying oxygen per protocol is the highest priority to
correct oxygenation while reassessing. This follows
, recognizing cues → take action in the clinical judgment
cycle.
• A: Pursed-lip breathing can help COPD patients but is
lower priority when oxygenation is inadequate.
• C: Respiratory therapy consult is appropriate but delays
immediate correction of hypoxemia.
• D: Upright positioning may help ventilation but ambulation
when SpO₂ is 88% and RR 28 is unsafe before oxygenation
is improved.
Teaching Point: Correct hypoxemia immediately; reassess and
then escalate care.
Citation: Ignatavicius et al., 2023, Ch. 2: Recognizing Cues and
Taking Action
2
Reference: Ch. 1: Overview of Professional Nursing Concepts —
Safety & Teamwork/Delegation
Question Stem: A newly licensed nurse on a med–surg unit is
managing four patients. Which task is most appropriate to
delegate to an experienced unlicensed assistive personnel
(UAP)?
A. Obtain capillary glucose for an insulin-dependent patient
scheduled for surgery.
B. Reinforce teaching about incentive spirometer use to a
,postop patient.
C. Assist a stable postoperative patient from bed to bedside
chair using a transfer belt.
D. Administer oral antibiotics to a patient with community-
acquired pneumonia.
Correct Answer: C
Rationales:
• Correct (C): Ambulation/assistance with transfers for a
stable patient is within UAP scope when trained;
delegation requires stable patient and clear instructions.
• A: Capillary glucose may be delegated in some settings, but
an insulin-dependent patient preop requires RN judgment
and documentation in many policies.
• B: Reinforcement of teaching often requires clinical
judgment and assessment of learning—RN responsibility.
• D: Medication administration is an RN role and should not
be delegated to UAP.
Teaching Point: Delegate stable, routine ADLs to trained UAPs;
keep assessments and meds for RNs.
Citation: Ignatavicius et al., 2023, Ch. 1: Teamwork, Delegation,
and Safety
3
, Reference: Ch. 3: Overview of Health Concepts — Homeostasis,
Inflammation, and Infection Control
Question Stem: A patient with an infected foot wound has a
temperature of 38.9°C, tachycardia, and leukocytosis. Which
nursing intervention best reflects understanding of systemic
inflammatory response and infection control?
A. Obtain wound culture before administering the first dose of
antibiotics.
B. Place the patient in protective isolation to prevent acquiring
other infections.
C. Begin antipyretic therapy and schedule a CT scan
immediately.
D. Teach family about using alcohol-based hand rubs at home.
Correct Answer: A
Rationales:
• Correct (A): Obtaining cultures prior to antibiotics
maximizes diagnostic yield and guides targeted therapy —
consistent with infection management and antimicrobial
stewardship.
• B: Protective isolation is for immunocompromised
patients; this patient is infectious, so standard + contact
precautions as indicated are appropriate.
• C: Antipyretics are supportive but cultures guide therapy;
CT is not first-line unless deep tissue involvement
suspected.
