Medical-Surgical Nursing
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
Item 1
1. Reference: Ch. 1: Nursing Process and Clinical Judgment
(Assessment & Diagnosis)
2. Question Stem: A 62-year-old postoperative patient
reports new-onset chest tightness and slight shortness of
breath on day 1 after abdominal surgery. Which nursing
action is the priority?
3. Options:
A. Encourage the patient to use the incentive spirometer
every hour while awake.
B. Assess vital signs and oxygen saturation, and perform
focused cardiopulmonary assessment.
C. Administer the prescribed opioid analgesic for pain
relief.
D. Notify the surgeon about the patient's symptoms.
4. Correct Answer: B
, 5. Rationales:
• Correct (B): Performing immediate assessment (vitals,
SpO₂, focused cardiopulmonary exam) is the highest-
priority action to identify hemodynamic or respiratory
compromise and guide next steps. This follows the
assessment → diagnosis phase of the nursing process and
clinical judgment frameworks.
• Incorrect (A): Incentive spirometry is appropriate for
prevention of atelectasis but is not the first action when
new cardiopulmonary symptoms appear.
• Incorrect (C): Administering opioid analgesic may relieve
pain but could mask symptoms or depress respiration;
assessment must precede medication administration.
• Incorrect (D): Notifying the surgeon may be required after
assessment; immediate assessment is necessary first to
provide accurate information.
6. Teaching Point: Always assess first to prioritize
interventions and detect acute deterioration.
7. Citation: Ignatavicius et al., 2024, Ch. 1: Nursing Process
and Clinical Judgment
Item 2
1. Reference: Ch. 1: Clinical Judgment Model and Decision-
Making
,2. Question Stem: A nurse uses the Clinical Judgment Model
and identifies multiple possible causes of a patient's
sudden confusion (opioids, electrolyte imbalance, hypoxia,
infection). What is the best next step to prioritize
diagnostic data?
3. Options:
A. Start broad empirical treatments for all suspected
causes simultaneously.
B. Order a complete metabolic panel and pulse oximetry
first.
C. Reassess the patient and obtain targeted diagnostics
based on most likely causes.
D. Call the primary provider and request a psychiatric
consult.
4. Correct Answer: C
5. Rationales:
• Correct (C): Reassessing the patient and selecting targeted
diagnostics reflects clinical judgment—narrowing
hypotheses and using focused data to support or refute
the most likely causes.
• Incorrect (A): Treating for all possible causes without
targeted data risks harm and unnecessary interventions.
• Incorrect (B): A metabolic panel and pulse oximetry may
be helpful, but immediate bedside reassessment often
, yields essential clues (airway, oxygenation, glucose) before
labs.
• Incorrect (D): Psychiatric consult is premature for acute
onset confusion; medical causes should be evaluated first.
6. Teaching Point: Use focused reassessment to test
hypotheses and guide targeted diagnostics.
7. Citation: Ignatavicius et al., 2024, Ch. 1: Clinical Judgment
Model and Decision-Making
Item 3
1. Reference: Ch. 1: Patient Safety and Risk Reduction
Strategies (Fall Prevention)
2. Question Stem: An older adult admitted for heart failure
has some mobility limitations but wants to walk to the
bathroom independently. Which action by the nurse best
balances safety and patient autonomy?
3. Options:
A. Place the patient on strict bedrest and inform them
walking is not allowed.
B. Ask the patient to wait and have nursing assist when
staff are available.
C. Conduct a fall-risk assessment, provide a gait belt, and
assist the patient as needed.
11th Edition
• Author(s)Donna D. Ignatavicius; Cherie R. Rebar; Nicole M.
Heimgartner
TEST BANK
Item 1
1. Reference: Ch. 1: Nursing Process and Clinical Judgment
(Assessment & Diagnosis)
2. Question Stem: A 62-year-old postoperative patient
reports new-onset chest tightness and slight shortness of
breath on day 1 after abdominal surgery. Which nursing
action is the priority?
3. Options:
A. Encourage the patient to use the incentive spirometer
every hour while awake.
B. Assess vital signs and oxygen saturation, and perform
focused cardiopulmonary assessment.
C. Administer the prescribed opioid analgesic for pain
relief.
D. Notify the surgeon about the patient's symptoms.
4. Correct Answer: B
, 5. Rationales:
• Correct (B): Performing immediate assessment (vitals,
SpO₂, focused cardiopulmonary exam) is the highest-
priority action to identify hemodynamic or respiratory
compromise and guide next steps. This follows the
assessment → diagnosis phase of the nursing process and
clinical judgment frameworks.
• Incorrect (A): Incentive spirometry is appropriate for
prevention of atelectasis but is not the first action when
new cardiopulmonary symptoms appear.
• Incorrect (C): Administering opioid analgesic may relieve
pain but could mask symptoms or depress respiration;
assessment must precede medication administration.
• Incorrect (D): Notifying the surgeon may be required after
assessment; immediate assessment is necessary first to
provide accurate information.
6. Teaching Point: Always assess first to prioritize
interventions and detect acute deterioration.
7. Citation: Ignatavicius et al., 2024, Ch. 1: Nursing Process
and Clinical Judgment
Item 2
1. Reference: Ch. 1: Clinical Judgment Model and Decision-
Making
,2. Question Stem: A nurse uses the Clinical Judgment Model
and identifies multiple possible causes of a patient's
sudden confusion (opioids, electrolyte imbalance, hypoxia,
infection). What is the best next step to prioritize
diagnostic data?
3. Options:
A. Start broad empirical treatments for all suspected
causes simultaneously.
B. Order a complete metabolic panel and pulse oximetry
first.
C. Reassess the patient and obtain targeted diagnostics
based on most likely causes.
D. Call the primary provider and request a psychiatric
consult.
4. Correct Answer: C
5. Rationales:
• Correct (C): Reassessing the patient and selecting targeted
diagnostics reflects clinical judgment—narrowing
hypotheses and using focused data to support or refute
the most likely causes.
• Incorrect (A): Treating for all possible causes without
targeted data risks harm and unnecessary interventions.
• Incorrect (B): A metabolic panel and pulse oximetry may
be helpful, but immediate bedside reassessment often
, yields essential clues (airway, oxygenation, glucose) before
labs.
• Incorrect (D): Psychiatric consult is premature for acute
onset confusion; medical causes should be evaluated first.
6. Teaching Point: Use focused reassessment to test
hypotheses and guide targeted diagnostics.
7. Citation: Ignatavicius et al., 2024, Ch. 1: Clinical Judgment
Model and Decision-Making
Item 3
1. Reference: Ch. 1: Patient Safety and Risk Reduction
Strategies (Fall Prevention)
2. Question Stem: An older adult admitted for heart failure
has some mobility limitations but wants to walk to the
bathroom independently. Which action by the nurse best
balances safety and patient autonomy?
3. Options:
A. Place the patient on strict bedrest and inform them
walking is not allowed.
B. Ask the patient to wait and have nursing assist when
staff are available.
C. Conduct a fall-risk assessment, provide a gait belt, and
assist the patient as needed.
