Ignatavicius: Medical-Surgical Nursing, 10th Edition

Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing

Answer Key – NCLEX Examination Challenges, Clinical Judgment Challenges, and

Mastery Questions

Answer Key – NCLEX Examination Challenges

NCLEX Examination Challenge 1-1

Safe, Effective Care Environment

Which nursing activities may be safely delegated to competent unlicensed nursing personnel?
Select all that apply.

A. Discharge teaching

B. Blood pressure monitoring

C. Gastrostomy feeding

D. Urinary catheterization

E. Oxygen administration

F. Ambulation assistance

Answer: C, D

Rationale: Choices B and E are already part of the routine care of the AP which does not meet
the definition of delegated responsibilities. Discharge teaching (Choice A) is not an activity,
skills, or procedure and requires an RN to perform. If the AP is trained and competent to
perform a gastrostomy tube feeding or oxygen administration, the nurse may delegate those
skills.

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NCLEX Examination Challenge 1-2

Physiological Integrity

A nurse assures a client experiencing abdominal surgical pain that comfort measures, including
drug therapy, will be provided as the client needs them. Which ethical principles apply in the
situation? Select all that apply.

A. Beneficence

B. Social justice

C. Autonomy

D. Fidelity

E. Veracity

Answers: A, D, E

Rationale: In this situation, the nurse is planning to provide positive measures (“good”) for the
client (beneficence) (Choice A) and is obligated to follow-through with this promise (fidelity)
(Choice D) and be truthful (veracity) (Choice E). The client is not autonomous because of
inability to self-manage care (Choice C). Social justice is about fairness and does not apply in
this scenario (Choice B).

Answer Key – Clinical Judgment Challenges

None.

Answer Key – Mastery Questions

1.The nurse provides an SBAR handoff communication regarding a client whose blood pressure
and respiratory rate have decreased. Where will the nurse include these data as part of the SBAR
format?

A. Situation

B. Background

C. Assessment

D. Recommendation

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Answer: A

Rationale: The client’s data reflects what is happening at the time of the handoff communication
and reflects the Situation being shared. It is the first step in the SBAR communication.

2.The nurse collaborates with the registered dietitian nutritionist to improve the nutritional status
of clients on a hospital unit. Which priority professional nursing concepts apply in this situation?
Select all that apply.

A. Quality Improvement

B. Ethics

C. Health Care Disparities

D. Systems Thinking

E. Teamwork and Collaboration

Answers: A, D, E

Rationale: Quality Improvement and Systems Thinking are more global concepts and usually
examine care for more than one client Choices A and D). By collaborating with the dietitian, the
concept of Teamwork and Collaboration apply (Choice E). From the information in the situation
provided, the concepts of Ethics and Health care Disparities are not evident (Choices B and C).

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