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
Reference: Ch. 1 — Professional Nursing — Professional Nursing
Practice
Stem: A med-surg RN on a busy surgical unit is assigned three
patients, one of whom is post-op day 1 with increasing
restlessness, O₂ saturation 92% on 2 L, and a new low-grade
fever. Using professional standards, which immediate action
best reflects the nurse’s priority?
A. Reassess the patient’s respiratory status and notify the
surgeon.
,B. Administer PRN acetaminophen for fever and chart.
C. Delegate vital signs every 2 hours to the nursing assistant.
D. Call the rapid response team immediately.
Correct answer: A
Rationales — Correct: Reassessing aligns with professional
standards to prioritize data collection before escalation;
identifying early respiratory compromise supports recognition
and analysis in the clinical judgment model. Immediate
assessment guides safe, evidence-based decisions.
Rationales — Incorrect: B delays assessment of potential
respiratory infection or atelectasis. C inappropriately delegates
initial assessment of a change in status. D is premature without
assessment indicating unstable airway/integument or
hemodynamic collapse.
Teaching point: Reassess first when a patient’s status changes;
data guide escalation.
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 — Standards of
Professional Nursing Practice
Stem: A nurse prepares to administer a medication ordered via
electronic health record (EHR). The nurse discovers the order is
incomplete (dose missing). Based on standards of practice,
what should the nurse do first?
,A. Hold the medication until a clarified order is obtained.
B. Administer half the usual dose and document rationale.
C. Ask the charge nurse to sign off on the order.
D. Use a previous dose from the patient’s chart and proceed.
Correct answer: A
Rationales — Correct: Holding the medication until clarification
meets standards of safe practice and prevents medication
errors; this reflects Analyze→Plan in the CJM by preventing
harm.
Rationales — Incorrect: B and D are unsafe, nonstandard dose
modifications without prescriber clarification. C shifts
responsibility without resolving the incomplete order.
Teaching point: Verify and clarify incomplete orders—never
guess doses.
Citation: Harding et al. (2023). Ch. 1.
3.
Reference: Ch. 1 — Professional Nursing — Domain of Nursing
Practice
Stem: A nurse educator asks a staff nurse how the nursing
domain differs from medical practice during handover. Which
response best reflects the nursing domain?
A. Nursing primarily prescribes therapy based on diagnosis.
B. Nursing focuses on holistic, patient-centered care including
psychosocial needs.
C. Nursing only implements orders from physicians.
, D. Nursing evaluates only physical outcomes, not patient
preferences.
Correct answer: B
Rationales — Correct: The nursing domain emphasizes holistic,
patient-centered assessments and interventions (physical,
psychosocial), consistent with Lewis’s scope and the nurse’s role
in care coordination and advocacy.
Rationales — Incorrect: A, C, and D misrepresent scope—
nurses do more than implement orders and evaluate both
clinical and patient-centered outcomes.
Teaching point: Nursing’s domain is holistic and patient-
centered.
Citation: Harding et al. (2023). Ch. 1.
4.
Reference: Ch. 1 — Professional Nursing — Definitions of
Nursing
Stem: A unit leader is revising job descriptions to reflect
contemporary nursing definitions. Which phrase best belongs in
the definition to guide safe practice?
A. “Nursing solely documents physician directives.”
B. “Nursing integrates evidence, clinical judgment, and patient
values.”
C. “Nursing’s role is primarily clerical record-keeping.”
D. “Nursing functions independently of other health
disciplines.”
ASSESSMENT AND MANAGEMENT OF
CLINICAL PROBLEMS, SINGLE VOLUME
12TH EDITION
• AUTHOR(S)MARIANN M. HARDING;
JEFFREY KWONG; DEBRA HAGLER;
COURTNEY REINISCH
TEST BANK
Reference: Ch. 1 — Professional Nursing — Professional Nursing
Practice
Stem: A med-surg RN on a busy surgical unit is assigned three
patients, one of whom is post-op day 1 with increasing
restlessness, O₂ saturation 92% on 2 L, and a new low-grade
fever. Using professional standards, which immediate action
best reflects the nurse’s priority?
A. Reassess the patient’s respiratory status and notify the
surgeon.
,B. Administer PRN acetaminophen for fever and chart.
C. Delegate vital signs every 2 hours to the nursing assistant.
D. Call the rapid response team immediately.
Correct answer: A
Rationales — Correct: Reassessing aligns with professional
standards to prioritize data collection before escalation;
identifying early respiratory compromise supports recognition
and analysis in the clinical judgment model. Immediate
assessment guides safe, evidence-based decisions.
Rationales — Incorrect: B delays assessment of potential
respiratory infection or atelectasis. C inappropriately delegates
initial assessment of a change in status. D is premature without
assessment indicating unstable airway/integument or
hemodynamic collapse.
Teaching point: Reassess first when a patient’s status changes;
data guide escalation.
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 — Standards of
Professional Nursing Practice
Stem: A nurse prepares to administer a medication ordered via
electronic health record (EHR). The nurse discovers the order is
incomplete (dose missing). Based on standards of practice,
what should the nurse do first?
,A. Hold the medication until a clarified order is obtained.
B. Administer half the usual dose and document rationale.
C. Ask the charge nurse to sign off on the order.
D. Use a previous dose from the patient’s chart and proceed.
Correct answer: A
Rationales — Correct: Holding the medication until clarification
meets standards of safe practice and prevents medication
errors; this reflects Analyze→Plan in the CJM by preventing
harm.
Rationales — Incorrect: B and D are unsafe, nonstandard dose
modifications without prescriber clarification. C shifts
responsibility without resolving the incomplete order.
Teaching point: Verify and clarify incomplete orders—never
guess doses.
Citation: Harding et al. (2023). Ch. 1.
3.
Reference: Ch. 1 — Professional Nursing — Domain of Nursing
Practice
Stem: A nurse educator asks a staff nurse how the nursing
domain differs from medical practice during handover. Which
response best reflects the nursing domain?
A. Nursing primarily prescribes therapy based on diagnosis.
B. Nursing focuses on holistic, patient-centered care including
psychosocial needs.
C. Nursing only implements orders from physicians.
, D. Nursing evaluates only physical outcomes, not patient
preferences.
Correct answer: B
Rationales — Correct: The nursing domain emphasizes holistic,
patient-centered assessments and interventions (physical,
psychosocial), consistent with Lewis’s scope and the nurse’s role
in care coordination and advocacy.
Rationales — Incorrect: A, C, and D misrepresent scope—
nurses do more than implement orders and evaluate both
clinical and patient-centered outcomes.
Teaching point: Nursing’s domain is holistic and patient-
centered.
Citation: Harding et al. (2023). Ch. 1.
4.
Reference: Ch. 1 — Professional Nursing — Definitions of
Nursing
Stem: A unit leader is revising job descriptions to reflect
contemporary nursing definitions. Which phrase best belongs in
the definition to guide safe practice?
A. “Nursing solely documents physician directives.”
B. “Nursing integrates evidence, clinical judgment, and patient
values.”
C. “Nursing’s role is primarily clerical record-keeping.”
D. “Nursing functions independently of other health
disciplines.”
