LEWIS'S MEDICAL-SURGICAL NURSING
ASSESSMENT AND MANAGEMENT OF
CLINICAL PROBLEMS, SINGLE VOLUME
12TH EDITION
• AUTHOR(S)MARIANN M. HARDING;
JEFFREY KWONG; DEBRA HAGLER;
COURTNEY REINISCH
TEST BANK
1
Reference: Ch. 1 — Professional Nursing — Domain of Nursing
Practice / Standards of Professional Nursing Practice
Stem: A newly licensed RN is assigned to a postoperative
patient with analgesic PCA. During shift report the RN
recognizes inconsistent documentation about pain assessment
frequency. What should the nurse do first to ensure safe,
evidence-based care and professional accountability?
A. Continue current care and document an additional
,assessment every 4 hours.
B. Clarify expectations with the charge nurse and review the
unit pain assessment protocol.
C. Ask the UAP to monitor the patient’s pain and notify the RN if
pain score >5.
D. Reduce opioid dose to prevent oversedation until
assessments are consistent.
Correct answer: B
Rationales — Correct: Choosing B reflects professional
accountability and use of evidence (Lewis): clarify standards
and confirm unit protocol before changing care. This follows
CJM: Recognize inconsistent data → Analyze by comparing to
standards → Plan to confirm protocol → Intervene by discussing
with charge nurse. It prevents unsafe unilateral changes and
supports system-level correction.
Incorrect A: Documenting additional assessments without
clarifying the standard may conflict with unit policy and
bypasses team communication.
Incorrect C: Delegating pain monitoring to UAP without RN
oversight for PCA is unsafe and violates scope/standards.
Incorrect D: Reducing opioids without assessment or prescriber
order risks undertreating pain and is outside RN scope.
Teaching point: Verify unit protocols and clarify with nurse
leadership before altering care.
Citation: Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C.
(2023). Lewis’s Medical-Surgical Nursing (12th Ed.). Ch. 1.
,2
Reference: Ch. 1 — Professional Nursing — Definitions of
Nursing / Nursing’s View of Humanity
Stem: A nurse is developing a plan for a patient with heart
failure who prefers traditional herbal remedies. Which action
best integrates nursing’s view of humanity and promotes
patient-centered, culturally competent care?
A. Educate the patient that herbal remedies are not evidence-
based and discontinue them.
B. Document the patient’s preferences and explore how the
remedies might interact with prescribed medications.
C. Report the use of herbs to the provider and insist they be
stopped immediately.
D. Replace prescribed medications with comparable herbal
treatments the patient trusts.
Correct answer: B
Rationales — Correct: B respects patient-centered care and
culturally sensitive nursing practice from Lewis; nurse
recognizes patient values, gathers data about potential
interactions, and plans safe care. CJM: Recognize preference →
Analyze risks (drug interactions) → Plan education/coordination
→ Intervene with informed recommendations. This balances
respect for beliefs with safety.
Incorrect A: Abrupt dismissal of patient beliefs undermines
trust and is not consistent with nursing’s holistic view.
Incorrect C: Reporting without assessment or collaboration may
erode therapeutic relationship and bypass shared decision-
, making.
Incorrect D: Replacing prescribed meds without provider
collaboration is unsafe and outside nursing scope.
Teaching point: Elicit patient preferences and assess safety
before advising changes.
Citation: Harding et al. (2023). Ch. 1.
3
Reference: Ch. 1 — Professional Nursing — Scope of Nursing
Practice / Delegation and Assignment
Stem: During a busy shift the RN must assign tasks for a stable
postoperative patient. Which task is appropriate to delegate to
a trained UAP while maintaining safe nursing practice?
A. Teach the patient how to use incentive spirometry and
evaluate technique.
B. Assist the patient with ambulation to the bathroom and
record observed gait.
C. Administer the patient’s PRN analgesic and document pain
response.
D. Conduct an initial head-to-toe assessment after transfer from
PACU.
Correct answer: B
Rationales — Correct: B is a delegated, non-invasive ADL
appropriate for a UAP when patient is stable; RN remains
responsible for supervision and interpreting findings. CJM:
Recognize task suitability → Analyze patient stability → Plan
ASSESSMENT AND MANAGEMENT OF
CLINICAL PROBLEMS, SINGLE VOLUME
12TH EDITION
• AUTHOR(S)MARIANN M. HARDING;
JEFFREY KWONG; DEBRA HAGLER;
COURTNEY REINISCH
TEST BANK
1
Reference: Ch. 1 — Professional Nursing — Domain of Nursing
Practice / Standards of Professional Nursing Practice
Stem: A newly licensed RN is assigned to a postoperative
patient with analgesic PCA. During shift report the RN
recognizes inconsistent documentation about pain assessment
frequency. What should the nurse do first to ensure safe,
evidence-based care and professional accountability?
A. Continue current care and document an additional
,assessment every 4 hours.
B. Clarify expectations with the charge nurse and review the
unit pain assessment protocol.
C. Ask the UAP to monitor the patient’s pain and notify the RN if
pain score >5.
D. Reduce opioid dose to prevent oversedation until
assessments are consistent.
Correct answer: B
Rationales — Correct: Choosing B reflects professional
accountability and use of evidence (Lewis): clarify standards
and confirm unit protocol before changing care. This follows
CJM: Recognize inconsistent data → Analyze by comparing to
standards → Plan to confirm protocol → Intervene by discussing
with charge nurse. It prevents unsafe unilateral changes and
supports system-level correction.
Incorrect A: Documenting additional assessments without
clarifying the standard may conflict with unit policy and
bypasses team communication.
Incorrect C: Delegating pain monitoring to UAP without RN
oversight for PCA is unsafe and violates scope/standards.
Incorrect D: Reducing opioids without assessment or prescriber
order risks undertreating pain and is outside RN scope.
Teaching point: Verify unit protocols and clarify with nurse
leadership before altering care.
Citation: Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C.
(2023). Lewis’s Medical-Surgical Nursing (12th Ed.). Ch. 1.
,2
Reference: Ch. 1 — Professional Nursing — Definitions of
Nursing / Nursing’s View of Humanity
Stem: A nurse is developing a plan for a patient with heart
failure who prefers traditional herbal remedies. Which action
best integrates nursing’s view of humanity and promotes
patient-centered, culturally competent care?
A. Educate the patient that herbal remedies are not evidence-
based and discontinue them.
B. Document the patient’s preferences and explore how the
remedies might interact with prescribed medications.
C. Report the use of herbs to the provider and insist they be
stopped immediately.
D. Replace prescribed medications with comparable herbal
treatments the patient trusts.
Correct answer: B
Rationales — Correct: B respects patient-centered care and
culturally sensitive nursing practice from Lewis; nurse
recognizes patient values, gathers data about potential
interactions, and plans safe care. CJM: Recognize preference →
Analyze risks (drug interactions) → Plan education/coordination
→ Intervene with informed recommendations. This balances
respect for beliefs with safety.
Incorrect A: Abrupt dismissal of patient beliefs undermines
trust and is not consistent with nursing’s holistic view.
Incorrect C: Reporting without assessment or collaboration may
erode therapeutic relationship and bypass shared decision-
, making.
Incorrect D: Replacing prescribed meds without provider
collaboration is unsafe and outside nursing scope.
Teaching point: Elicit patient preferences and assess safety
before advising changes.
Citation: Harding et al. (2023). Ch. 1.
3
Reference: Ch. 1 — Professional Nursing — Scope of Nursing
Practice / Delegation and Assignment
Stem: During a busy shift the RN must assign tasks for a stable
postoperative patient. Which task is appropriate to delegate to
a trained UAP while maintaining safe nursing practice?
A. Teach the patient how to use incentive spirometry and
evaluate technique.
B. Assist the patient with ambulation to the bathroom and
record observed gait.
C. Administer the patient’s PRN analgesic and document pain
response.
D. Conduct an initial head-to-toe assessment after transfer from
PACU.
Correct answer: B
Rationales — Correct: B is a delegated, non-invasive ADL
appropriate for a UAP when patient is stable; RN remains
responsible for supervision and interpreting findings. CJM:
Recognize task suitability → Analyze patient stability → Plan
