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 —
Clinical Judgment Process
Question Stem: An adult patient on a med-surg floor develops
sudden dyspnea and O₂ saturation falls from 96% to 86% on
room air. The nurse’s first action should be:
Options:
A. Administer an albuterol nebulizer per PRN order.
B. Reassess lung sounds and check oxygen delivery equipment.
C. Call the rapid response team immediately.
D. Elevate head of bed and apply supplemental oxygen.
Correct Answer: D
Rationales:
• Correct (D): Elevating the head and applying oxygen are
immediate, evidence-based actions to improve
oxygenation and ventilation while the nurse continues
, assessment — consistent with the clinical judgment
process to address the most urgent physiological need.
• A: Administering albuterol might be appropriate for
bronchospasm but is not the immediate first step before
supporting oxygenation.
• B: Reassessment is required but should occur while oxygen
and positioning are initiated; delaying oxygenation is
unsafe.
• C: Activating rapid response is appropriate if the patient
remains unstable after immediate interventions; it is not
the first immediate action.
Teaching Point: Always address airway/oxygenation first —
position and oxygen precede diagnostics.
Citation: Ignatavicius et al., 2024, Ch. 2: Clinical Judgment
and Systems Thinking
2
Reference: Ch. 1: Overview of Professional Nursing Concepts for
Medical-Surgical Nursing — Prioritization & Delegation
Question Stem: A nurse is delegating tasks to a CNA and LPN on
a busy med-surg unit. Which task is most appropriate to assign
to the CNA?
Options:
A. Administering a scheduled IV push opioid.
B. Performing hourly rounding and assisting with toileting.
,C. Completing a focused physical assessment of a new admit.
D. Titrating oxygen to maintain SpO₂ >92%.
Correct Answer: B
Rationales:
• Correct (B): CNAs are appropriate for routine ADLs and
hourly rounding tasks; these support safety and patient
comfort and free RNs for assessment/clinical judgment.
• A: IV push opioid is outside CNA scope and requires RN or
authorized provider.
• C: Focused assessments of new admissions require RN
clinical judgment and are not delegated to CNAs.
• D: Titrating oxygen based on assessment is scope of an RN
or LPN per facility policy; not typically a CNA task.
Teaching Point: Delegate tasks based on scope,
competence, and patient need.
Citation: Ignatavicius et al., 2024, Ch. 1: Overview of
Professional Nursing Concepts
3
Reference: Ch. 3: Overview of Health Concepts for Medical-
Surgical Nursing — Infection Prevention & Safety
Question Stem: A postoperative patient has a temperature of
38.4°C (101.1°F), wound redness, and mild tachycardia. Which
next nursing action best reflects evidence-based infection
surveillance?
, Options:
A. Document findings and reassess in 4 hours.
B. Obtain wound culture and notify the surgeon.
C. Start broad-spectrum antibiotics without consulting provider.
D. Apply warm compresses and encourage oral fluids.
Correct Answer: B
Rationales:
• Correct (B): Obtaining cultures before antibiotics and
notifying the surgeon follow infection control and
diagnostic principles to identify causative organisms and
guide therapy.
• A: Waiting to reassess delays diagnosis and treatment of a
suspected surgical site infection.
• C: Initiating antibiotics without orders breaches scope and
may mask culture results; antibiotics should be started per
provider after cultures are obtained.
• D: Comfort measures are supportive but insufficient alone
for suspected wound infection.
Teaching Point: Culture before antibiotics and escalate to
the provider for suspected infection.
Citation: Ignatavicius et al., 2024, Ch. 3: Overview of
Health Concepts
4
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 —
Clinical Judgment Process
Question Stem: An adult patient on a med-surg floor develops
sudden dyspnea and O₂ saturation falls from 96% to 86% on
room air. The nurse’s first action should be:
Options:
A. Administer an albuterol nebulizer per PRN order.
B. Reassess lung sounds and check oxygen delivery equipment.
C. Call the rapid response team immediately.
D. Elevate head of bed and apply supplemental oxygen.
Correct Answer: D
Rationales:
• Correct (D): Elevating the head and applying oxygen are
immediate, evidence-based actions to improve
oxygenation and ventilation while the nurse continues
, assessment — consistent with the clinical judgment
process to address the most urgent physiological need.
• A: Administering albuterol might be appropriate for
bronchospasm but is not the immediate first step before
supporting oxygenation.
• B: Reassessment is required but should occur while oxygen
and positioning are initiated; delaying oxygenation is
unsafe.
• C: Activating rapid response is appropriate if the patient
remains unstable after immediate interventions; it is not
the first immediate action.
Teaching Point: Always address airway/oxygenation first —
position and oxygen precede diagnostics.
Citation: Ignatavicius et al., 2024, Ch. 2: Clinical Judgment
and Systems Thinking
2
Reference: Ch. 1: Overview of Professional Nursing Concepts for
Medical-Surgical Nursing — Prioritization & Delegation
Question Stem: A nurse is delegating tasks to a CNA and LPN on
a busy med-surg unit. Which task is most appropriate to assign
to the CNA?
Options:
A. Administering a scheduled IV push opioid.
B. Performing hourly rounding and assisting with toileting.
,C. Completing a focused physical assessment of a new admit.
D. Titrating oxygen to maintain SpO₂ >92%.
Correct Answer: B
Rationales:
• Correct (B): CNAs are appropriate for routine ADLs and
hourly rounding tasks; these support safety and patient
comfort and free RNs for assessment/clinical judgment.
• A: IV push opioid is outside CNA scope and requires RN or
authorized provider.
• C: Focused assessments of new admissions require RN
clinical judgment and are not delegated to CNAs.
• D: Titrating oxygen based on assessment is scope of an RN
or LPN per facility policy; not typically a CNA task.
Teaching Point: Delegate tasks based on scope,
competence, and patient need.
Citation: Ignatavicius et al., 2024, Ch. 1: Overview of
Professional Nursing Concepts
3
Reference: Ch. 3: Overview of Health Concepts for Medical-
Surgical Nursing — Infection Prevention & Safety
Question Stem: A postoperative patient has a temperature of
38.4°C (101.1°F), wound redness, and mild tachycardia. Which
next nursing action best reflects evidence-based infection
surveillance?
, Options:
A. Document findings and reassess in 4 hours.
B. Obtain wound culture and notify the surgeon.
C. Start broad-spectrum antibiotics without consulting provider.
D. Apply warm compresses and encourage oral fluids.
Correct Answer: B
Rationales:
• Correct (B): Obtaining cultures before antibiotics and
notifying the surgeon follow infection control and
diagnostic principles to identify causative organisms and
guide therapy.
• A: Waiting to reassess delays diagnosis and treatment of a
suspected surgical site infection.
• C: Initiating antibiotics without orders breaches scope and
may mask culture results; antibiotics should be started per
provider after cultures are obtained.
• D: Comfort measures are supportive but insufficient alone
for suspected wound infection.
Teaching Point: Culture before antibiotics and escalate to
the provider for suspected infection.
Citation: Ignatavicius et al., 2024, Ch. 3: Overview of
Health Concepts
4
