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 (Application / Analysis)
Reference: Ch. 2: Clinical Judgment and Systems Thinking —
Recognizing Cues & Prioritizing Care
Stem: A 68-year-old post-op client with COPD develops sudden
increased work of breathing and SpO₂ 85% on 2 L nasal cannula.
Which action should the nurse perform first?
A. Increase oxygen to 6 L via nasal cannula.
B. Sit the client upright and assess respiratory rate and breath
sounds.
C. Call the rapid response team immediately.
D. Administer a prescribed PRN albuterol nebulizer.
Correct Answer: B
Rationales:
, • Correct (B): Sitting the client upright and performing
focused respiratory assessment allows immediate
recognition of severity and directs next actions;
assessment-first aligns with clinical judgment and prevents
inappropriate interventions.
• A: Increasing oxygen without reassessment risks delaying
correct diagnosis (airway obstruction, pneumothorax) and
may be ineffective; device change should follow
assessment.
• C: Activating rapid response may be required if
deterioration is confirmed, but assessment identifies
whether immediate escalation is necessary.
• D: Administering bronchodilator without assessment and
order confirmation may be inappropriate if the cause is
nonbronchospasm (e.g., secretions, pneumothorax).
Teaching Point: Assess before treating—clinical judgment
begins with focused data collection.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 2:
Recognizing Cues & Prioritizing Care
2 (Application / Analysis)
Reference: Ch. 1: Overview of Professional Nursing Concepts —
Accountability, Delegation, and Scope of Practice
Stem: The RN is supervising a team caring for four med-surgical
patients. Which task is most appropriate to delegate to an
,experienced LPN?
A. Complete admission history and physical assessment.
B. Administer scheduled intramuscular (IM) analgesic and
document response.
C. Teach discharge instructions about wound care and return
precautions.
D. Perform initial triage for a patient reporting chest pain.
Correct Answer: B
Rationales:
• Correct (B): LPNs may safely administer routine IM
medications and document responses within their scope;
the RN remains accountable for delegation and follow-up.
• A: Admission assessment requires RN judgment and
comprehensive data collection—not delegable.
• C: Teaching discharge with complex decision-making and
evaluation of learning is RN role.
• D: Triage for chest pain requires rapid clinical judgment
and is the RN’s responsibility.
Teaching Point: Delegate stable, routine tasks within staff scope
while retaining accountability.
Citation: Ignatavicius et al., 2024, Ch. 1: Delegation &
Accountability
3 (Evaluation / Synthesis)
, Reference: Ch. 3: Overview of Health Concepts — Nutrition and
Wound Healing
Stem: A patient with a stage III pressure injury has albumin 2.8
g/dL and recent 10% unintentional weight loss. Which plan
change best addresses wound healing barriers?
A. Increase protein-calorie intake and consult dietitian for high-
protein supplements.
B. Apply topical antimicrobial ointment daily and continue
current diet.
C. Decrease caloric intake to prevent further weight gain during
immobility.
D. Schedule dressing changes every 72 hours to allow wound
rest.
Correct Answer: A
Rationales:
• Correct (A): Low albumin and weight loss indicate protein-
calorie malnutrition; increasing protein/calories and
dietitian referral address systemic factors essential for
healing.
• B: Topical antimicrobials don’t correct nutritional deficits;
nutrition must be optimized for repair.
• C: Decreasing calories worsens malnutrition and impairs
healing.
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 (Application / Analysis)
Reference: Ch. 2: Clinical Judgment and Systems Thinking —
Recognizing Cues & Prioritizing Care
Stem: A 68-year-old post-op client with COPD develops sudden
increased work of breathing and SpO₂ 85% on 2 L nasal cannula.
Which action should the nurse perform first?
A. Increase oxygen to 6 L via nasal cannula.
B. Sit the client upright and assess respiratory rate and breath
sounds.
C. Call the rapid response team immediately.
D. Administer a prescribed PRN albuterol nebulizer.
Correct Answer: B
Rationales:
, • Correct (B): Sitting the client upright and performing
focused respiratory assessment allows immediate
recognition of severity and directs next actions;
assessment-first aligns with clinical judgment and prevents
inappropriate interventions.
• A: Increasing oxygen without reassessment risks delaying
correct diagnosis (airway obstruction, pneumothorax) and
may be ineffective; device change should follow
assessment.
• C: Activating rapid response may be required if
deterioration is confirmed, but assessment identifies
whether immediate escalation is necessary.
• D: Administering bronchodilator without assessment and
order confirmation may be inappropriate if the cause is
nonbronchospasm (e.g., secretions, pneumothorax).
Teaching Point: Assess before treating—clinical judgment
begins with focused data collection.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 2:
Recognizing Cues & Prioritizing Care
2 (Application / Analysis)
Reference: Ch. 1: Overview of Professional Nursing Concepts —
Accountability, Delegation, and Scope of Practice
Stem: The RN is supervising a team caring for four med-surgical
patients. Which task is most appropriate to delegate to an
,experienced LPN?
A. Complete admission history and physical assessment.
B. Administer scheduled intramuscular (IM) analgesic and
document response.
C. Teach discharge instructions about wound care and return
precautions.
D. Perform initial triage for a patient reporting chest pain.
Correct Answer: B
Rationales:
• Correct (B): LPNs may safely administer routine IM
medications and document responses within their scope;
the RN remains accountable for delegation and follow-up.
• A: Admission assessment requires RN judgment and
comprehensive data collection—not delegable.
• C: Teaching discharge with complex decision-making and
evaluation of learning is RN role.
• D: Triage for chest pain requires rapid clinical judgment
and is the RN’s responsibility.
Teaching Point: Delegate stable, routine tasks within staff scope
while retaining accountability.
Citation: Ignatavicius et al., 2024, Ch. 1: Delegation &
Accountability
3 (Evaluation / Synthesis)
, Reference: Ch. 3: Overview of Health Concepts — Nutrition and
Wound Healing
Stem: A patient with a stage III pressure injury has albumin 2.8
g/dL and recent 10% unintentional weight loss. Which plan
change best addresses wound healing barriers?
A. Increase protein-calorie intake and consult dietitian for high-
protein supplements.
B. Apply topical antimicrobial ointment daily and continue
current diet.
C. Decrease caloric intake to prevent further weight gain during
immobility.
D. Schedule dressing changes every 72 hours to allow wound
rest.
Correct Answer: A
Rationales:
• Correct (A): Low albumin and weight loss indicate protein-
calorie malnutrition; increasing protein/calories and
dietitian referral address systemic factors essential for
healing.
• B: Topical antimicrobials don’t correct nutritional deficits;
nutrition must be optimized for repair.
• C: Decreasing calories worsens malnutrition and impairs
healing.
