Linton and Matteson's Medical-Surgical
Practical Nursing in Canada, 1st Edition
Authors:
Katherine Poser,Adrianne Dill Linton,Mary
Ann Matteson
TEST BANK.
Medical–Surgical Practical Nursing — Test Bank
Chapter 1: Aspects of Medical-Surgical Nursing
1. (Standard — Single best answer)
A 72-year-old client recovering from hip replacement
reports a new onset of confusion, pulse 110/min,
respiratory rate 24/min, and temperature 38.4°C. As the
practical nurse (PN), which action should you perform
, first?
A. Administer the scheduled antipyretic.
B. Reorient the client and perform a mini-mental status
check.
C. Obtain oxygen saturation and apply oxygen if < 92%.
D. Notify the surgeon immediately.
Answer: C. Obtain oxygen saturation and apply oxygen if < 92%.
Rationale: The client shows signs of possible hypoxia and
systemic infection; immediate assessment of oxygenation is
highest priority to prevent deterioration. Reorientation and
antipyretic are secondary; notifying surgeon follows after
immediate stabilization.
(Linton & Matteson — Chapter 1: Aspects of Medical-Surgical
Nursing)
2. (Priority — First action)
You receive report on four clients. Which client should you
see first?
A. Postoperative client, 2 hours post-op, pain 7/10
receiving PRN opioid 30 minutes ago.
B. Client with urinary retention who is awaiting bladder
scan.
C. Client admitted with chest pain: ECG pending, pain 8/10,
diaphoresis.
D. Client scheduled for morning discharge needing final
teaching.
,Answer: C. Client admitted with chest pain: ECG pending, pain
8/10, diaphoresis.
Rationale: Signs of acute coronary syndrome (severe chest pain,
diaphoresis) indicate immediate risk of life-threatening
deterioration — highest priority.
(Linton & Matteson — Chapter 1)
3. (SATA — Select all that apply)
Which actions may a PN delegate to an unregulated care
provider (UCP) for a medically stable client? (Select all that
apply.)
A. Assist with ambulation using a gait belt.
B. Administer oral pain medication.
C. Measure and record vital signs every 4 hours.
D. Provide routine oral hygiene.
E. Teach the client self-administered insulin technique.
Answers: A, C, D.
Rationale: UCPs may safely assist with ambulation (with proper
training), take and record routine vitals, and perform hygiene.
Medication administration and teaching self-care skills that
require assessment or judgment remain RN/PN responsibilities.
(Linton & Matteson — Chapter 1)
4. (Scenario — Clinical judgment)
A client with chronic obstructive pulmonary disease
, (COPD) uses home oxygen and is anxious about smoking
cessation. The client tells you they were smoking on the
unit in the restroom. What is the most appropriate PN
action?
A. Report the client to the charge nurse for disciplinary
action.
B. Remove the oxygen source until the client is ready to
follow rules.
C. Assess for immediate safety risks (oxygen, embers),
provide brief counseling, and notify the primary nurse.
D. Document the behaviour and take no further action.
Answer: C. Assess for immediate safety risks (oxygen, embers),
provide brief counseling, and notify the primary nurse.
Rationale: Safety assessment (risk of fire/exacerbation) is
immediate. Brief, nonjudgmental counseling and escalation to
primary nurse are appropriate; punitive actions and unilateral
removal of oxygen could harm the client.
(Linton & Matteson — Chapter 1)
5. (Standard — Single best answer)
A client receiving heparin has an aPTT result that is twice
the control value. The PN should:
A. Continue the infusion and recheck aPTT in 24 hours.
B. Stop the infusion and prepare protamine sulfate.
C. Document and notify the physician for possible dose
Practical Nursing in Canada, 1st Edition
Authors:
Katherine Poser,Adrianne Dill Linton,Mary
Ann Matteson
TEST BANK.
Medical–Surgical Practical Nursing — Test Bank
Chapter 1: Aspects of Medical-Surgical Nursing
1. (Standard — Single best answer)
A 72-year-old client recovering from hip replacement
reports a new onset of confusion, pulse 110/min,
respiratory rate 24/min, and temperature 38.4°C. As the
practical nurse (PN), which action should you perform
, first?
A. Administer the scheduled antipyretic.
B. Reorient the client and perform a mini-mental status
check.
C. Obtain oxygen saturation and apply oxygen if < 92%.
D. Notify the surgeon immediately.
Answer: C. Obtain oxygen saturation and apply oxygen if < 92%.
Rationale: The client shows signs of possible hypoxia and
systemic infection; immediate assessment of oxygenation is
highest priority to prevent deterioration. Reorientation and
antipyretic are secondary; notifying surgeon follows after
immediate stabilization.
(Linton & Matteson — Chapter 1: Aspects of Medical-Surgical
Nursing)
2. (Priority — First action)
You receive report on four clients. Which client should you
see first?
A. Postoperative client, 2 hours post-op, pain 7/10
receiving PRN opioid 30 minutes ago.
B. Client with urinary retention who is awaiting bladder
scan.
C. Client admitted with chest pain: ECG pending, pain 8/10,
diaphoresis.
D. Client scheduled for morning discharge needing final
teaching.
,Answer: C. Client admitted with chest pain: ECG pending, pain
8/10, diaphoresis.
Rationale: Signs of acute coronary syndrome (severe chest pain,
diaphoresis) indicate immediate risk of life-threatening
deterioration — highest priority.
(Linton & Matteson — Chapter 1)
3. (SATA — Select all that apply)
Which actions may a PN delegate to an unregulated care
provider (UCP) for a medically stable client? (Select all that
apply.)
A. Assist with ambulation using a gait belt.
B. Administer oral pain medication.
C. Measure and record vital signs every 4 hours.
D. Provide routine oral hygiene.
E. Teach the client self-administered insulin technique.
Answers: A, C, D.
Rationale: UCPs may safely assist with ambulation (with proper
training), take and record routine vitals, and perform hygiene.
Medication administration and teaching self-care skills that
require assessment or judgment remain RN/PN responsibilities.
(Linton & Matteson — Chapter 1)
4. (Scenario — Clinical judgment)
A client with chronic obstructive pulmonary disease
, (COPD) uses home oxygen and is anxious about smoking
cessation. The client tells you they were smoking on the
unit in the restroom. What is the most appropriate PN
action?
A. Report the client to the charge nurse for disciplinary
action.
B. Remove the oxygen source until the client is ready to
follow rules.
C. Assess for immediate safety risks (oxygen, embers),
provide brief counseling, and notify the primary nurse.
D. Document the behaviour and take no further action.
Answer: C. Assess for immediate safety risks (oxygen, embers),
provide brief counseling, and notify the primary nurse.
Rationale: Safety assessment (risk of fire/exacerbation) is
immediate. Brief, nonjudgmental counseling and escalation to
primary nurse are appropriate; punitive actions and unilateral
removal of oxygen could harm the client.
(Linton & Matteson — Chapter 1)
5. (Standard — Single best answer)
A client receiving heparin has an aPTT result that is twice
the control value. The PN should:
A. Continue the infusion and recheck aPTT in 24 hours.
B. Stop the infusion and prepare protamine sulfate.
C. Document and notify the physician for possible dose
