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
Item 1
Reference: Ch. 2: Clinical Judgment and Systems Thinking —
Clinical Judgment Model
Question Stem: A 68-year-old postop hip replacement patient
has sudden shortness of breath and oxygen saturation 86% on 2
L/min nasal cannula. Using clinical judgment (recognize-analyze-
respond), which action should the nurse perform first?
A. Increase oxygen to 4 L/min via nasal cannula.
B. Perform a focused respiratory assessment and call rapid
response.
C. Administer PRN opioid analgesic for pain and reassess.
D. Encourage deep breathing and incentive spirometry every
hour.
Correct Answer: B
,Rationales:
• Correct (B): Focused assessment and early escalation
identify life-threatening causes (e.g., PE, atelectasis) and
initiates timely team response; this follows the clinical
judgment cycle of recognizing and responding.
• Incorrect (A): Increasing oxygen without assessment can
mask deterioration and may be insufficient if immediate
intervention/transfer is needed.
• Incorrect (C): Opioids may worsen hypoventilation;
treating pain before assessment risks harm.
• Incorrect (D): Incentive spirometry is
preventive/therapeutic but too slow as the first action in
acute desaturation.
Teaching Point: Rapid assessment and escalation are priority
when patients have sudden hypoxia.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 2:
Clinical Judgment and Systems Thinking
Item 2
Reference: Ch. 1: Overview of Professional Nursing Concepts —
Scope & Standards
Question Stem: A nurse is assigned four patients and must
delegate morning care tasks. Which task is best to assign to a
licensed practical nurse (LPN) on the team?
,A. Teach the newly diagnosed diabetic patient insulin injection
technique.
B. Perform and document a focused wound assessment for a
postoperative incision.
C. Administer scheduled subcutaneous insulin to a stable
patient.
D. Initiate discharge teaching and evaluate home safety for a
patient.
Correct Answer: C
Rationales:
• Correct (C): LPNs commonly administer scheduled
medications to stable patients under RN supervision; this is
appropriate delegation of a skilled, stable task.
• Incorrect (A): Teaching and competency evaluation are RN
responsibilities requiring assessment and evaluation.
• Incorrect (B): Wound assessment and documenting
changes that could affect plan of care require RN
assessment skill.
• Incorrect (D): Discharge teaching, complex teaching, and
home safety evaluation require RN judgment and holistic
assessment.
Teaching Point: Delegate tasks based on stability, complexity,
and scope of practice.
, Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Overview of Professional Nursing Concepts
Item 3
Reference: Ch. 3: Overview of Health Concepts — Homeostasis
and Stress Response
Question Stem: A patient with uncontrolled hyperthyroidism
reports palpitations, weight loss, and heat intolerance. Which
physiologic concept best explains the patient's increased
baseline metabolic rate?
A. Parasympathetic dominance causing increased digestion.
B. Excess thyroid hormone increasing cellular oxygen
consumption.
C. Decreased catecholamine sensitivity in peripheral tissues.
D. Upregulation of insulin receptors increasing glucose uptake.
Correct Answer: B
Rationales:
• Correct (B): Thyroid hormones increase basal metabolic
rate by upregulating cellular enzymes and increasing
oxygen consumption and heat production.
• Incorrect (A): Parasympathetic activity decreases
metabolic rate and promotes rest-and-digest; it does not
explain hypermetabolism.
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
Item 1
Reference: Ch. 2: Clinical Judgment and Systems Thinking —
Clinical Judgment Model
Question Stem: A 68-year-old postop hip replacement patient
has sudden shortness of breath and oxygen saturation 86% on 2
L/min nasal cannula. Using clinical judgment (recognize-analyze-
respond), which action should the nurse perform first?
A. Increase oxygen to 4 L/min via nasal cannula.
B. Perform a focused respiratory assessment and call rapid
response.
C. Administer PRN opioid analgesic for pain and reassess.
D. Encourage deep breathing and incentive spirometry every
hour.
Correct Answer: B
,Rationales:
• Correct (B): Focused assessment and early escalation
identify life-threatening causes (e.g., PE, atelectasis) and
initiates timely team response; this follows the clinical
judgment cycle of recognizing and responding.
• Incorrect (A): Increasing oxygen without assessment can
mask deterioration and may be insufficient if immediate
intervention/transfer is needed.
• Incorrect (C): Opioids may worsen hypoventilation;
treating pain before assessment risks harm.
• Incorrect (D): Incentive spirometry is
preventive/therapeutic but too slow as the first action in
acute desaturation.
Teaching Point: Rapid assessment and escalation are priority
when patients have sudden hypoxia.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 2:
Clinical Judgment and Systems Thinking
Item 2
Reference: Ch. 1: Overview of Professional Nursing Concepts —
Scope & Standards
Question Stem: A nurse is assigned four patients and must
delegate morning care tasks. Which task is best to assign to a
licensed practical nurse (LPN) on the team?
,A. Teach the newly diagnosed diabetic patient insulin injection
technique.
B. Perform and document a focused wound assessment for a
postoperative incision.
C. Administer scheduled subcutaneous insulin to a stable
patient.
D. Initiate discharge teaching and evaluate home safety for a
patient.
Correct Answer: C
Rationales:
• Correct (C): LPNs commonly administer scheduled
medications to stable patients under RN supervision; this is
appropriate delegation of a skilled, stable task.
• Incorrect (A): Teaching and competency evaluation are RN
responsibilities requiring assessment and evaluation.
• Incorrect (B): Wound assessment and documenting
changes that could affect plan of care require RN
assessment skill.
• Incorrect (D): Discharge teaching, complex teaching, and
home safety evaluation require RN judgment and holistic
assessment.
Teaching Point: Delegate tasks based on stability, complexity,
and scope of practice.
, Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 1:
Overview of Professional Nursing Concepts
Item 3
Reference: Ch. 3: Overview of Health Concepts — Homeostasis
and Stress Response
Question Stem: A patient with uncontrolled hyperthyroidism
reports palpitations, weight loss, and heat intolerance. Which
physiologic concept best explains the patient's increased
baseline metabolic rate?
A. Parasympathetic dominance causing increased digestion.
B. Excess thyroid hormone increasing cellular oxygen
consumption.
C. Decreased catecholamine sensitivity in peripheral tissues.
D. Upregulation of insulin receptors increasing glucose uptake.
Correct Answer: B
Rationales:
• Correct (B): Thyroid hormones increase basal metabolic
rate by upregulating cellular enzymes and increasing
oxygen consumption and heat production.
• Incorrect (A): Parasympathetic activity decreases
metabolic rate and promotes rest-and-digest; it does not
explain hypermetabolism.
