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
1
Reference: Ch. 2: Clinical Judgment and Systems Thinking
— Recognizing Cues & Prioritization
Question stem: A stable postoperative patient on the
surgical unit reports sudden chest tightness and shortness
of breath. Vital signs: T 37.0°C, HR 110, RR 28, BP 138/76,
O₂ sat 89% on room air. Which nursing action is the highest
priority?
A. Offer a bronchodilator inhaler from the unit supply.
B. Apply supplemental oxygen and reassess respiratory
status.
C. Notify the surgeon to return to the bedside immediately.
D. Encourage the patient to perform incentive spirometry
every hour.
Correct answer: B
, Rationales:
• Correct (B): Apply supplemental oxygen and reassess —
immediate oxygenation support is priority when O₂
saturation is low; reassessment directs next interventions
per clinical judgment and airway/breathing prioritization.
• A: Bronchodilator may be appropriate for bronchospasm
but requires assessment and often an order; it is not first-
line for hypoxemia.
• C: Notifying the surgeon may be necessary depending on
cause, but first the nurse must stabilize oxygenation and
evaluate.
• D: Incentive spirometry is preventive/therapeutic for
atelectasis but inadequate for acute hypoxemia.
Teaching point: Prioritize interventions that address airway
and oxygenation first.
Citation: Ignatavicius et al., 2024, Ch. 2: Clinical Judgment
and Systems Thinking.
2
Reference: Ch. 1: Overview of Professional Nursing
Concepts — Delegation & Scope of Practice
Question stem: A registered nurse delegates morning vital
signs and a focused abdominal assessment to an
experienced LPN/LVN for a patient 24 hours post-
, appendectomy. Which task must the RN retain and
perform personally?
A. Administering the prescribed analgesic PRN.
B. Documenting the vital signs in the electronic record.
C. Interpreting assessment findings and adjusting the plan
of care.
D. Changing a dry, intact surgical dressing.
Correct answer: C
Rationales:
• Correct (C): Interpreting assessment data and adjusting the
plan of care is a nursing judgment and responsibility the
RN cannot delegate.
• A: Medication administration may be within LPN/LVN
scope depending on facility policy and state law; RN
oversight still required.
• B: Documentation can be done by the delegate but RN
remains accountable for accuracy.
• D: Dressing changes of a dry, intact wound may be
delegated in many settings, depending on policy.
Teaching point: RNs retain responsibility for clinical
judgment and care-plan modifications.
Citation: Ignatavicius et al., 2024, Ch. 1: Professional
Nursing Concepts.
, 3
Reference: Ch. 3: Overview of Health Concepts —
Immunity & Infection Control
Question stem: A patient with neutropenia (ANC 400) is
admitted with fever. Which nursing action best reflects
evidence-based practice to reduce infection risk?
A. Implementing protective (reverse) isolation precautions
and restricting flowers/visitors.
B. Placing the patient in standard precautions only and
monitoring closely.
C. Allowing fresh fruit and raw vegetables to maintain
nutrition.
D. Delaying empiric antibiotics until culture results return.
Correct answer: A
Rationales:
• Correct (A): Protective precautions, restricting potential
sources (flowers, large crowds) reduce exposure in severe
neutropenia; prompt protective measures align with
infection-prevention principles.
• B: Standard precautions alone are insufficient for severe
neutropenia; additional protective measures are indicated.
• C: Fresh, uncooked produce can harbor pathogens and is
contraindicated for severely immunocompromised
patients.
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
1
Reference: Ch. 2: Clinical Judgment and Systems Thinking
— Recognizing Cues & Prioritization
Question stem: A stable postoperative patient on the
surgical unit reports sudden chest tightness and shortness
of breath. Vital signs: T 37.0°C, HR 110, RR 28, BP 138/76,
O₂ sat 89% on room air. Which nursing action is the highest
priority?
A. Offer a bronchodilator inhaler from the unit supply.
B. Apply supplemental oxygen and reassess respiratory
status.
C. Notify the surgeon to return to the bedside immediately.
D. Encourage the patient to perform incentive spirometry
every hour.
Correct answer: B
, Rationales:
• Correct (B): Apply supplemental oxygen and reassess —
immediate oxygenation support is priority when O₂
saturation is low; reassessment directs next interventions
per clinical judgment and airway/breathing prioritization.
• A: Bronchodilator may be appropriate for bronchospasm
but requires assessment and often an order; it is not first-
line for hypoxemia.
• C: Notifying the surgeon may be necessary depending on
cause, but first the nurse must stabilize oxygenation and
evaluate.
• D: Incentive spirometry is preventive/therapeutic for
atelectasis but inadequate for acute hypoxemia.
Teaching point: Prioritize interventions that address airway
and oxygenation first.
Citation: Ignatavicius et al., 2024, Ch. 2: Clinical Judgment
and Systems Thinking.
2
Reference: Ch. 1: Overview of Professional Nursing
Concepts — Delegation & Scope of Practice
Question stem: A registered nurse delegates morning vital
signs and a focused abdominal assessment to an
experienced LPN/LVN for a patient 24 hours post-
, appendectomy. Which task must the RN retain and
perform personally?
A. Administering the prescribed analgesic PRN.
B. Documenting the vital signs in the electronic record.
C. Interpreting assessment findings and adjusting the plan
of care.
D. Changing a dry, intact surgical dressing.
Correct answer: C
Rationales:
• Correct (C): Interpreting assessment data and adjusting the
plan of care is a nursing judgment and responsibility the
RN cannot delegate.
• A: Medication administration may be within LPN/LVN
scope depending on facility policy and state law; RN
oversight still required.
• B: Documentation can be done by the delegate but RN
remains accountable for accuracy.
• D: Dressing changes of a dry, intact wound may be
delegated in many settings, depending on policy.
Teaching point: RNs retain responsibility for clinical
judgment and care-plan modifications.
Citation: Ignatavicius et al., 2024, Ch. 1: Professional
Nursing Concepts.
, 3
Reference: Ch. 3: Overview of Health Concepts —
Immunity & Infection Control
Question stem: A patient with neutropenia (ANC 400) is
admitted with fever. Which nursing action best reflects
evidence-based practice to reduce infection risk?
A. Implementing protective (reverse) isolation precautions
and restricting flowers/visitors.
B. Placing the patient in standard precautions only and
monitoring closely.
C. Allowing fresh fruit and raw vegetables to maintain
nutrition.
D. Delaying empiric antibiotics until culture results return.
Correct answer: A
Rationales:
• Correct (A): Protective precautions, restricting potential
sources (flowers, large crowds) reduce exposure in severe
neutropenia; prompt protective measures align with
infection-prevention principles.
• B: Standard precautions alone are insufficient for severe
neutropenia; additional protective measures are indicated.
• C: Fresh, uncooked produce can harbor pathogens and is
contraindicated for severely immunocompromised
patients.
