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 Decision-Making
Question Stem: A 62-year-old with COPD presents with
increased dyspnea, accessory muscle use, and SpO₂ 88%
on room air. Which nursing action should be performed
first?
A. Elevate head of bed and administer prescribed short-
acting bronchodilator via nebulizer.
B. Obtain arterial blood gas (ABG) to assess gas exchange.
C. Initiate controlled oxygen at 2 L/min via nasal cannula
and reassess.
D. Call respiratory therapy for noninvasive ventilation
(BiPAP).
Correct Answer: C
Rationale — Correct: Start controlled low-flow oxygen (2
L/min) to correct hypoxemia while monitoring for CO₂
,retention; immediate oxygen addresses the most urgent
physiologic need and is consistent with airway/ breathing
priority.
Rationale — A: Elevating HOB and bronchodilator are
appropriate but oxygen correction takes precedence to
improve tissue oxygenation immediately.
Rationale — B: ABG provides useful data but is diagnostic
— not the immediate stabilizing action.
Rationale — D: BiPAP may be needed if respiratory failure
progresses, but initiating low-flow oxygen and
reassessment precede escalation.
Teaching Point: Immediately treat hypoxemia with
controlled oxygen and continual reassessment.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 2:
Clinical Judgment and Systems Thinking.
2
Reference: Ch. 1: Overview of Professional Nursing
Concepts — Delegation & Scope of Practice
Question Stem: A new LPN reports to the RN that a stable
postoperative patient needs oral pain medication. Which
task should the RN delegate to the LPN?
A. Perform a full pain assessment and administer PRN oral
opioid per protocol.
B. Adjust the patient-controlled analgesia (PCA) settings.
C. Teach the patient nonpharmacologic pain-management
,techniques.
D. Evaluate the effectiveness of the opioid 15 minutes after
administration.
Correct Answer: A
Rationale — Correct: Delegating administration of
scheduled or PRN oral medications and performing
focused assessments is within LPN scope under RN
supervision for stable patients; RN retains responsibility for
overall care.
Rationale — B: PCA adjustments require RN or provider
authorization due to safety and titration complexity.
Rationale — C: Teaching complex self-management is an
RN responsibility requiring assessment and individualized
education.
Rationale — D: Evaluation of initial response and titration
decisions remain RN responsibilities due to clinical
judgment required.
Teaching Point: Delegate stable, routine tasks; retain
delegation of tasks requiring complex judgment.
Citation: Ignatavicius et al., 2024, Ch. 1: Overview of
Professional Nursing Concepts for Medical-Surgical
Nursing.
3
Reference: Ch. 3: Overview of Health Concepts —
Electrolytes & Fluid Balance
, Question Stem: A patient receiving an infusion of 0.9%
normal saline complains of headache and nausea. Serum
sodium returns at 128 mEq/L. Which nursing action best
reflects clinical reasoning?
A. Stop the infusion and notify the provider immediately.
B. Continue infusion; obtain a STAT serum osmolality and
review recent fluid intake.
C. Administer a hypertonic saline bolus (3% NaCl) as
ordered for hyponatremia.
D. Restrict oral fluids and monitor urine specific gravity
hourly.
Correct Answer: B
Rationale — Correct: Continue monitoring while obtaining
serum osmolality and reviewing inputs/outputs to
determine etiology; abrupt stopping may be inappropriate
without diagnostic data. Clinical judgment requires
assessment before major interventions.
Rationale — A: Stopping IV may be unnecessary and could
harm if patient requires maintenance fluids; assessment
first is preferred.
Rationale — C: Hypertonic saline is indicated only for
severe, symptomatic hyponatremia and with provider
order; not first step without osmolality assessment.
Rationale — D: Fluid restriction may be appropriate for
dilutional hyponatremia but should follow evaluation and
provider orders.
Teaching Point: Assess and obtain diagnostics before
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 Decision-Making
Question Stem: A 62-year-old with COPD presents with
increased dyspnea, accessory muscle use, and SpO₂ 88%
on room air. Which nursing action should be performed
first?
A. Elevate head of bed and administer prescribed short-
acting bronchodilator via nebulizer.
B. Obtain arterial blood gas (ABG) to assess gas exchange.
C. Initiate controlled oxygen at 2 L/min via nasal cannula
and reassess.
D. Call respiratory therapy for noninvasive ventilation
(BiPAP).
Correct Answer: C
Rationale — Correct: Start controlled low-flow oxygen (2
L/min) to correct hypoxemia while monitoring for CO₂
,retention; immediate oxygen addresses the most urgent
physiologic need and is consistent with airway/ breathing
priority.
Rationale — A: Elevating HOB and bronchodilator are
appropriate but oxygen correction takes precedence to
improve tissue oxygenation immediately.
Rationale — B: ABG provides useful data but is diagnostic
— not the immediate stabilizing action.
Rationale — D: BiPAP may be needed if respiratory failure
progresses, but initiating low-flow oxygen and
reassessment precede escalation.
Teaching Point: Immediately treat hypoxemia with
controlled oxygen and continual reassessment.
Citation: Ignatavicius, Rebar, & Heimgartner, 2024, Ch. 2:
Clinical Judgment and Systems Thinking.
2
Reference: Ch. 1: Overview of Professional Nursing
Concepts — Delegation & Scope of Practice
Question Stem: A new LPN reports to the RN that a stable
postoperative patient needs oral pain medication. Which
task should the RN delegate to the LPN?
A. Perform a full pain assessment and administer PRN oral
opioid per protocol.
B. Adjust the patient-controlled analgesia (PCA) settings.
C. Teach the patient nonpharmacologic pain-management
,techniques.
D. Evaluate the effectiveness of the opioid 15 minutes after
administration.
Correct Answer: A
Rationale — Correct: Delegating administration of
scheduled or PRN oral medications and performing
focused assessments is within LPN scope under RN
supervision for stable patients; RN retains responsibility for
overall care.
Rationale — B: PCA adjustments require RN or provider
authorization due to safety and titration complexity.
Rationale — C: Teaching complex self-management is an
RN responsibility requiring assessment and individualized
education.
Rationale — D: Evaluation of initial response and titration
decisions remain RN responsibilities due to clinical
judgment required.
Teaching Point: Delegate stable, routine tasks; retain
delegation of tasks requiring complex judgment.
Citation: Ignatavicius et al., 2024, Ch. 1: Overview of
Professional Nursing Concepts for Medical-Surgical
Nursing.
3
Reference: Ch. 3: Overview of Health Concepts —
Electrolytes & Fluid Balance
, Question Stem: A patient receiving an infusion of 0.9%
normal saline complains of headache and nausea. Serum
sodium returns at 128 mEq/L. Which nursing action best
reflects clinical reasoning?
A. Stop the infusion and notify the provider immediately.
B. Continue infusion; obtain a STAT serum osmolality and
review recent fluid intake.
C. Administer a hypertonic saline bolus (3% NaCl) as
ordered for hyponatremia.
D. Restrict oral fluids and monitor urine specific gravity
hourly.
Correct Answer: B
Rationale — Correct: Continue monitoring while obtaining
serum osmolality and reviewing inputs/outputs to
determine etiology; abrupt stopping may be inappropriate
without diagnostic data. Clinical judgment requires
assessment before major interventions.
Rationale — A: Stopping IV may be unnecessary and could
harm if patient requires maintenance fluids; assessment
first is preferred.
Rationale — C: Hypertonic saline is indicated only for
severe, symptomatic hyponatremia and with provider
order; not first step without osmolality assessment.
Rationale — D: Fluid restriction may be appropriate for
dilutional hyponatremia but should follow evaluation and
provider orders.
Teaching Point: Assess and obtain diagnostics before
