Test Bank - Medical-Surgical Nursing: Concepts for Clinical Judgment and
Collaborative Care (11th Edition by Ignatavicius) | Complete Chapters &
Explanations
A nurse is conducting an admission assessment on a client from a diverse
cultural background. Which action by the nurse best demonstrates competence
in client-focused care? [1]
A. Organizing the physical environment of the room to match standard hospital safety
guidelines.
B. Assessing how the client's cultural beliefs and traditions affect their view of
healthcare.
C. Informing the client and family about the strict timeline for all scheduled diagnostic
procedures.
D. Assuming the client's dietary needs match the standard low-sodium protocol of the
unit. [1]
Correct Answer: B [1]
Rationale:
B is correct: Competency in client-focused, patient-centered care requires the nurse to
focus on communication, respect, compassion, and cultural empowerment. Assessing
, how a client's culture influences their health beliefs helps tailor an individualized,
respectful plan of care. [1]
A is incorrect: Ensuring environmental safety is a basic nursing duty, but it does not
directly evaluate or implement individualized, culturally competent care. [1]
C is incorrect: Informing the client about timelines is standard administrative
communication, but it fails to address or integrate the client's personal preferences or
empowerment. [1]
D is incorrect: Stereotyping or making assumptions about a client's diet without an
individualized assessment violates the principles of patient-centered care.
Question 2: Clinical Judgment & Fluid Volume Excess
A nurse evaluates a client with chronic heart failure who was admitted with fluid
volume excess. Which of the following clinical findings indicates the highest
priority need for an immediate intervention based on the Airway-Breathing-
Circulation (ABC) framework? [1]
A. Pitting edema (2+) in both lower extremities and ankles.
B. A sudden weight gain of 3 pounds over the past 24 hours.
C. Bilateral crackles auscultated in the lower lung bases and an SpO2 of 88% on room
air.
D. Client reports feeling tired and fatigued when ambulating to the bathroom. [1]
Correct Answer: C
Rationale:
C is correct: Utilizing the ABC framework, crackles in the lungs coupled with hypoxia
(SpO2 88%) point directly to fluid accumulating in the alveolar spaces (Breathing issue).
This represents an immediate threat to oxygenation and requires urgent intervention
(e.g., oxygen therapy and diuretic administration). [1]
A is incorrect: Peripheral pitting edema is an expected finding in fluid volume excess
and chronic heart failure; while it requires management, it is not immediately life-
threatening.
B is incorrect: Weight gain confirms fluid retention, but it is a data trend rather than an
acute, life-threatening respiratory emergency.
D is incorrect: Fatigue during exertion is a common, chronic symptom of heart failure
due to decreased cardiac output and does not take priority over active respiratory
distress.
Question 3: Acid-Base Imbalances
, A nurse reviews the arterial blood gas (ABG) results for a client who has been
vomiting repeatedly for 24 hours. The results are: pH 7.51, PaCO2 43 mmHg, and
HCO3 32 mEq/L. Which acid-base imbalance should the nurse document?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis [1]
Correct Answer: D
Rationale:
D is correct: The client's pH is elevated (>7.45), indicating alkalosis. The bicarbonate
level (HCO3) is high (>26 mEq/L), which aligns with the elevated pH, making it a
metabolic issue. The PaCO2 is within normal limits (35–45 mmHg), indicating no
respiratory compensation yet. Loss of gastric acid via vomiting typically triggers
metabolic alkalosis.
A is incorrect: Respiratory acidosis requires a low pH (<7.35) and an elevated PaCO2
(>45 mmHg).
B is incorrect: Metabolic acidosis requires a low pH (<7.35) and a low HCO3 (<22
mEq/L).
C is incorrect: Respiratory alkalosis requires an elevated pH (>7.45) and a decreased
PaCO2 (<35 mmHg). [1]
Question 4: Concepts of Care for Older Adults
An older adult client is admitted to an acute care unit for a urinary tract infection
(UTI). The nurse notes that the client has become suddenly confused, agitated,
and is attempting to climb out of bed. The family states this is entirely
uncharacteristic behavior. Which condition should the nurse suspect?
A. Progressive Dementia
B. Acute Delirium
C. Normal Age-Related Cognitive Decline
D. Major Depressive Disorder
Correct Answer: B
Rationale:
B is correct: Delirium is characterized by an acute, abrupt, and fluctuating change in
mental status, often manifested as confusion and agitation. In older adults, physiological
stressors such as infections (UTIs), medications, or dehydration frequently trigger acute
delirium. It is completely reversible once the underlying cause is treated.
A is incorrect: Dementia is a chronic, progressive, and irreversible decline in cognitive
function that occurs gradually over months or years, not suddenly within a day.
, C is incorrect: Sudden, severe confusion and safety risks are never normal
consequences of aging.
D is incorrect: Depression in older adults may cause cognitive slowing or apathy, but it
does not present as an acute onset of severe, hyperactive confusion or agitation.
Question 5: Next-Generation NCLEX (NGN) Case Study Item
A nurse is assessing a client who returned to the medical-surgical unit 2 hours
ago following an open abdominal hysterectomy. The nurse notes the following
clinical data:
Vital Signs: BP: 92/56 mmHg, HR: 112 bpm, RR: 22/min, Temp: 37°C.
Physical Assessment: Abdominal dressing is saturated with bright red drainage; the
abdomen is rigid and tender upon palpation; the client is pale and reports feeling dizzy.
Which of the following actions should the nurse take immediately? (Select All that
Apply.)
A. Elevate the head of the bed to a high-Fowler's position.
B. Reinforce the surgical dressing and apply manual pressure over the site.
C. Notify the surgical provider immediately regarding the assessment findings.
D. Increase the rate of the prescribed maintenance intravenous fluids.
E. Administer the client's scheduled oral stool softener. [1]
Correct Answers: B, C, D
Rationale:
B is correct: The client is exhibiting signs of active hemorrhage and hypovolemic shock
(hypotension, tachycardia, saturated dressing, rigidity). Applying immediate pressure
helps control external bleeding.
C is correct: A rigid abdomen and deteriorating vital signs point to internal bleeding,
requiring emergency evaluation and potential surgical re-exploration by the provider.
D is correct: Increasing IV fluid rates helps expand intravascular volume to maintain
vital organ perfusion in a hemorrhaging client.
A is incorrect: High-Fowler's position can worsen hypotension and compromise
cerebral perfusion in a client experiencing hypovolemic shock. Modified Trendelenburg
or supine is preferred.
E is incorrect: Administering oral medications is inappropriate because this client is
unstable and will likely need to return to surgery (NPO status).
A nurse is caring for a client who is post-operative day 3 following an open
cholecystectomy. Which of the following local assessment findings should the
nurse identify as an early indicator of a localized wound infection rather than a
normal inflammatory response?
Collaborative Care (11th Edition by Ignatavicius) | Complete Chapters &
Explanations
A nurse is conducting an admission assessment on a client from a diverse
cultural background. Which action by the nurse best demonstrates competence
in client-focused care? [1]
A. Organizing the physical environment of the room to match standard hospital safety
guidelines.
B. Assessing how the client's cultural beliefs and traditions affect their view of
healthcare.
C. Informing the client and family about the strict timeline for all scheduled diagnostic
procedures.
D. Assuming the client's dietary needs match the standard low-sodium protocol of the
unit. [1]
Correct Answer: B [1]
Rationale:
B is correct: Competency in client-focused, patient-centered care requires the nurse to
focus on communication, respect, compassion, and cultural empowerment. Assessing
, how a client's culture influences their health beliefs helps tailor an individualized,
respectful plan of care. [1]
A is incorrect: Ensuring environmental safety is a basic nursing duty, but it does not
directly evaluate or implement individualized, culturally competent care. [1]
C is incorrect: Informing the client about timelines is standard administrative
communication, but it fails to address or integrate the client's personal preferences or
empowerment. [1]
D is incorrect: Stereotyping or making assumptions about a client's diet without an
individualized assessment violates the principles of patient-centered care.
Question 2: Clinical Judgment & Fluid Volume Excess
A nurse evaluates a client with chronic heart failure who was admitted with fluid
volume excess. Which of the following clinical findings indicates the highest
priority need for an immediate intervention based on the Airway-Breathing-
Circulation (ABC) framework? [1]
A. Pitting edema (2+) in both lower extremities and ankles.
B. A sudden weight gain of 3 pounds over the past 24 hours.
C. Bilateral crackles auscultated in the lower lung bases and an SpO2 of 88% on room
air.
D. Client reports feeling tired and fatigued when ambulating to the bathroom. [1]
Correct Answer: C
Rationale:
C is correct: Utilizing the ABC framework, crackles in the lungs coupled with hypoxia
(SpO2 88%) point directly to fluid accumulating in the alveolar spaces (Breathing issue).
This represents an immediate threat to oxygenation and requires urgent intervention
(e.g., oxygen therapy and diuretic administration). [1]
A is incorrect: Peripheral pitting edema is an expected finding in fluid volume excess
and chronic heart failure; while it requires management, it is not immediately life-
threatening.
B is incorrect: Weight gain confirms fluid retention, but it is a data trend rather than an
acute, life-threatening respiratory emergency.
D is incorrect: Fatigue during exertion is a common, chronic symptom of heart failure
due to decreased cardiac output and does not take priority over active respiratory
distress.
Question 3: Acid-Base Imbalances
, A nurse reviews the arterial blood gas (ABG) results for a client who has been
vomiting repeatedly for 24 hours. The results are: pH 7.51, PaCO2 43 mmHg, and
HCO3 32 mEq/L. Which acid-base imbalance should the nurse document?
A. Respiratory Acidosis
B. Metabolic Acidosis
C. Respiratory Alkalosis
D. Metabolic Alkalosis [1]
Correct Answer: D
Rationale:
D is correct: The client's pH is elevated (>7.45), indicating alkalosis. The bicarbonate
level (HCO3) is high (>26 mEq/L), which aligns with the elevated pH, making it a
metabolic issue. The PaCO2 is within normal limits (35–45 mmHg), indicating no
respiratory compensation yet. Loss of gastric acid via vomiting typically triggers
metabolic alkalosis.
A is incorrect: Respiratory acidosis requires a low pH (<7.35) and an elevated PaCO2
(>45 mmHg).
B is incorrect: Metabolic acidosis requires a low pH (<7.35) and a low HCO3 (<22
mEq/L).
C is incorrect: Respiratory alkalosis requires an elevated pH (>7.45) and a decreased
PaCO2 (<35 mmHg). [1]
Question 4: Concepts of Care for Older Adults
An older adult client is admitted to an acute care unit for a urinary tract infection
(UTI). The nurse notes that the client has become suddenly confused, agitated,
and is attempting to climb out of bed. The family states this is entirely
uncharacteristic behavior. Which condition should the nurse suspect?
A. Progressive Dementia
B. Acute Delirium
C. Normal Age-Related Cognitive Decline
D. Major Depressive Disorder
Correct Answer: B
Rationale:
B is correct: Delirium is characterized by an acute, abrupt, and fluctuating change in
mental status, often manifested as confusion and agitation. In older adults, physiological
stressors such as infections (UTIs), medications, or dehydration frequently trigger acute
delirium. It is completely reversible once the underlying cause is treated.
A is incorrect: Dementia is a chronic, progressive, and irreversible decline in cognitive
function that occurs gradually over months or years, not suddenly within a day.
, C is incorrect: Sudden, severe confusion and safety risks are never normal
consequences of aging.
D is incorrect: Depression in older adults may cause cognitive slowing or apathy, but it
does not present as an acute onset of severe, hyperactive confusion or agitation.
Question 5: Next-Generation NCLEX (NGN) Case Study Item
A nurse is assessing a client who returned to the medical-surgical unit 2 hours
ago following an open abdominal hysterectomy. The nurse notes the following
clinical data:
Vital Signs: BP: 92/56 mmHg, HR: 112 bpm, RR: 22/min, Temp: 37°C.
Physical Assessment: Abdominal dressing is saturated with bright red drainage; the
abdomen is rigid and tender upon palpation; the client is pale and reports feeling dizzy.
Which of the following actions should the nurse take immediately? (Select All that
Apply.)
A. Elevate the head of the bed to a high-Fowler's position.
B. Reinforce the surgical dressing and apply manual pressure over the site.
C. Notify the surgical provider immediately regarding the assessment findings.
D. Increase the rate of the prescribed maintenance intravenous fluids.
E. Administer the client's scheduled oral stool softener. [1]
Correct Answers: B, C, D
Rationale:
B is correct: The client is exhibiting signs of active hemorrhage and hypovolemic shock
(hypotension, tachycardia, saturated dressing, rigidity). Applying immediate pressure
helps control external bleeding.
C is correct: A rigid abdomen and deteriorating vital signs point to internal bleeding,
requiring emergency evaluation and potential surgical re-exploration by the provider.
D is correct: Increasing IV fluid rates helps expand intravascular volume to maintain
vital organ perfusion in a hemorrhaging client.
A is incorrect: High-Fowler's position can worsen hypotension and compromise
cerebral perfusion in a client experiencing hypovolemic shock. Modified Trendelenburg
or supine is preferred.
E is incorrect: Administering oral medications is inappropriate because this client is
unstable and will likely need to return to surgery (NPO status).
A nurse is caring for a client who is post-operative day 3 following an open
cholecystectomy. Which of the following local assessment findings should the
nurse identify as an early indicator of a localized wound infection rather than a
normal inflammatory response?
