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 — Patient-Centered Care / Clinical Judgment
Stem: A 72-year-old post-op patient on the med-surgical unit
tells you he’s short of breath and looks anxious. Respirations
26/min, SpO₂ 89% on room air, BP 142/84, HR 110; lung
auscultation reveals bilateral crackles. Which nursing action is
the priority?
A. Encourage the patient to cough and deep-breath and
reassess in 15 minutes.
,B. Place the patient on supplemental oxygen at 2 L/min via
nasal cannula and notify the surgeon.
C. Obtain a portable chest x-ray and then call respiratory
therapy.
D. Elevate the head of the bed, apply pulse oximetry continuous
monitoring, and prepare oxygen.
Correct answer: D
Rationale — Correct (3–4 sentences): Elevating the head
improves ventilation, immediate continuous pulse oximetry
detects rapid deterioration, and preparing oxygen readies
treatment without delay — priority actions per Lewis
(airway/oxygenation first). This follows Recognize → Analyze →
Plan in the NCSBN CJM by identifying respiratory compromise
and initiating immediate supportive measures. Oxygen delivery
is prepared so administration can occur quickly if SpO₂ remains
low.
Rationales — Incorrect:
A. Waiting 15 minutes delays needed oxygenation and is unsafe
for SpO₂ 89%.
B. Starting oxygen is appropriate but calling the surgeon first
misses immediate bedside stabilization steps.
C. A chest x-ray is useful but not first — stabilization takes
priority over diagnostics.
Teaching point: Immediate bedside oxygenation and
positioning take priority for acute hypoxemia.
,Citation: Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C.
(2023). Lewis’s Medical-Surgical Nursing (12th Ed.). Ch. 1.
2
Reference: Ch. 1 — Delegation and Assignment / Safety
Stem: You are the RN team leader caring for four patients.
Which task is most appropriate to delegate to an experienced
unlicensed assistive personnel (UAP)?
A. Obtain daily weights for a patient with heart failure receiving
IV diuretics.
B. Teach a diabetic patient how to adjust insulin doses for meal
changes.
C. Assess a postoperative patient’s wound and document
findings.
D. Administer scheduled oral warfarin to a patient and monitor
INR.
Correct answer: A
Rationale — Correct (3–4 sentences): Obtaining weights is
within UAP scope when stable and routine; it’s a delegated
data-collection task and supports monitoring fluid status per
Lewis. Teaching, wound assessment, and medication
administration are nursing judgment tasks requiring an RN’s
skills. Delegation should match task complexity, patient stability,
and UAP competence.
, Rationales — Incorrect:
B. Teaching insulin dosing requires RN assessment and clinical
judgment.
C. Wound assessment requires professional evaluation and
cannot be delegated.
D. Warfarin administration and INR interpretation are RN
responsibilities.
Teaching point: Delegate stable, routine data collection to
UAPs; retain assessment, teaching, and med administration.
Citation: Harding et al. (2023). Ch. 1.
3
Reference: Ch. 1 — Safety / National Patient Safety Goals
Stem: During handoff at shift change, you notice the incoming
RN did not perform bedside patient identification before
transferring report. The patient is drowsy and on opioids. What
should you do first?
A. Complete the handoff verbally and assume identification will
occur later.
B. Politely stop the report and perform bedside identification
now using two identifiers.
C. Ask the charge nurse to reassign the incoming RN because of
the breach.
D. Document the incomplete identification in the chart and
continue report.
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 — Patient-Centered Care / Clinical Judgment
Stem: A 72-year-old post-op patient on the med-surgical unit
tells you he’s short of breath and looks anxious. Respirations
26/min, SpO₂ 89% on room air, BP 142/84, HR 110; lung
auscultation reveals bilateral crackles. Which nursing action is
the priority?
A. Encourage the patient to cough and deep-breath and
reassess in 15 minutes.
,B. Place the patient on supplemental oxygen at 2 L/min via
nasal cannula and notify the surgeon.
C. Obtain a portable chest x-ray and then call respiratory
therapy.
D. Elevate the head of the bed, apply pulse oximetry continuous
monitoring, and prepare oxygen.
Correct answer: D
Rationale — Correct (3–4 sentences): Elevating the head
improves ventilation, immediate continuous pulse oximetry
detects rapid deterioration, and preparing oxygen readies
treatment without delay — priority actions per Lewis
(airway/oxygenation first). This follows Recognize → Analyze →
Plan in the NCSBN CJM by identifying respiratory compromise
and initiating immediate supportive measures. Oxygen delivery
is prepared so administration can occur quickly if SpO₂ remains
low.
Rationales — Incorrect:
A. Waiting 15 minutes delays needed oxygenation and is unsafe
for SpO₂ 89%.
B. Starting oxygen is appropriate but calling the surgeon first
misses immediate bedside stabilization steps.
C. A chest x-ray is useful but not first — stabilization takes
priority over diagnostics.
Teaching point: Immediate bedside oxygenation and
positioning take priority for acute hypoxemia.
,Citation: Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C.
(2023). Lewis’s Medical-Surgical Nursing (12th Ed.). Ch. 1.
2
Reference: Ch. 1 — Delegation and Assignment / Safety
Stem: You are the RN team leader caring for four patients.
Which task is most appropriate to delegate to an experienced
unlicensed assistive personnel (UAP)?
A. Obtain daily weights for a patient with heart failure receiving
IV diuretics.
B. Teach a diabetic patient how to adjust insulin doses for meal
changes.
C. Assess a postoperative patient’s wound and document
findings.
D. Administer scheduled oral warfarin to a patient and monitor
INR.
Correct answer: A
Rationale — Correct (3–4 sentences): Obtaining weights is
within UAP scope when stable and routine; it’s a delegated
data-collection task and supports monitoring fluid status per
Lewis. Teaching, wound assessment, and medication
administration are nursing judgment tasks requiring an RN’s
skills. Delegation should match task complexity, patient stability,
and UAP competence.
, Rationales — Incorrect:
B. Teaching insulin dosing requires RN assessment and clinical
judgment.
C. Wound assessment requires professional evaluation and
cannot be delegated.
D. Warfarin administration and INR interpretation are RN
responsibilities.
Teaching point: Delegate stable, routine data collection to
UAPs; retain assessment, teaching, and med administration.
Citation: Harding et al. (2023). Ch. 1.
3
Reference: Ch. 1 — Safety / National Patient Safety Goals
Stem: During handoff at shift change, you notice the incoming
RN did not perform bedside patient identification before
transferring report. The patient is drowsy and on opioids. What
should you do first?
A. Complete the handoff verbally and assume identification will
occur later.
B. Politely stop the report and perform bedside identification
now using two identifiers.
C. Ask the charge nurse to reassign the incoming RN because of
the breach.
D. Document the incomplete identification in the chart and
continue report.
