Lewis's Medical-Surgical Nursing in Canada
Assessment and Management of Clinical
Problems
• 5th Edition - June 15, 2022
• Latest edition
• Authors: Jane Tyerman, Shelley Cobbett,
Mariann M. Harding, Jeffrey Kwong, Dottie
Roberts, Debra Hagler, Courtney Reinisch
TEST BANK
1. A nurse is caring for four clients on a medical unit. Which
client should the nurse assess first?
A. Client with stable angina reporting mild chest discomfort
rated 2/10
B. Client with COPD requesting assistance to the bathroom
C. Client 1 day post-op with new onset confusion
D. Client awaiting discharge teaching for hypertension
Answer: C
,Rationale: Acute confusion in a postoperative client may
indicate hypoxia, infection, medication effect, or metabolic
imbalance and requires immediate assessment. Prioritization
follows the principle of recognizing acute change in condition.
Reference: Lewis et al., 5th ed., Ch. 1 – Clinical Judgment and
Prioritization in Medical-Surgical Nursing Practice.
2. The nurse is applying clinical judgment when caring for a
deteriorating patient. Which action reflects the “analyzing
cues” phase of clinical reasoning?
A. Collecting vital signs
B. Comparing current findings with baseline data
C. Calling the rapid response team
D. Documenting in the electronic record
Answer: B
Rationale: Analyzing cues involves interpreting assessment data
and comparing with baseline to determine significance.
Collecting data is cue recognition; calling RRT is action.
Reference: Lewis et al., 5th ed., Ch. 1 – Clinical Judgment Model
in Nursing Practice.
3. Which situation best demonstrates advocacy in medical-
surgical nursing practice?
,A. Administering medications on time
B. Following provider orders without question
C. Questioning a medication dosage that seems unusually high
D. Delegating vital signs to unregulated care personnel
Answer: C
Rationale: Advocacy involves protecting the client’s safety by
questioning unclear or potentially unsafe orders.
Reference: Lewis et al., 5th ed., Ch. 1 – Professional Nursing
Roles and Advocacy.
4. A nurse identifies that a patient’s potassium is critically
elevated. What is the priority nursing action?
A. Document the lab result
B. Notify the health care provider immediately
C. Recheck the value in 4 hours
D. Provide dietary teaching
Answer: B
Rationale: Hyperkalemia is life-threatening due to risk of
dysrhythmias. Immediate notification aligns with patient safety
and early intervention principles.
Reference: Lewis et al., 5th ed., Ch. 1 – Safety and Clinical
Judgment in Acute Care.
, 5. Which statement best reflects evidence-informed nursing
practice?
A. “I do it this way because I was taught that in school.”
B. “This intervention worked for my last patient.”
C. “Research supports early mobilization to reduce
complications.”
D. “The physician prefers this approach.”
Answer: C
Rationale: Evidence-informed practice integrates best current
evidence with clinical expertise and patient preferences.
Reference: Lewis et al., 5th ed., Ch. 1 – Evidence-Informed
Nursing Practice.
6. A newly graduated nurse asks about the difference between
critical thinking and clinical judgment. Which explanation is
most accurate?
A. They are identical concepts.
B. Clinical judgment is the application of critical thinking to
patient care decisions.
C. Critical thinking only applies in emergencies.
D. Clinical judgment is based solely on experience.
Answer: B
Rationale: Critical thinking is a cognitive process; clinical
judgment is its application in real clinical situations.
Assessment and Management of Clinical
Problems
• 5th Edition - June 15, 2022
• Latest edition
• Authors: Jane Tyerman, Shelley Cobbett,
Mariann M. Harding, Jeffrey Kwong, Dottie
Roberts, Debra Hagler, Courtney Reinisch
TEST BANK
1. A nurse is caring for four clients on a medical unit. Which
client should the nurse assess first?
A. Client with stable angina reporting mild chest discomfort
rated 2/10
B. Client with COPD requesting assistance to the bathroom
C. Client 1 day post-op with new onset confusion
D. Client awaiting discharge teaching for hypertension
Answer: C
,Rationale: Acute confusion in a postoperative client may
indicate hypoxia, infection, medication effect, or metabolic
imbalance and requires immediate assessment. Prioritization
follows the principle of recognizing acute change in condition.
Reference: Lewis et al., 5th ed., Ch. 1 – Clinical Judgment and
Prioritization in Medical-Surgical Nursing Practice.
2. The nurse is applying clinical judgment when caring for a
deteriorating patient. Which action reflects the “analyzing
cues” phase of clinical reasoning?
A. Collecting vital signs
B. Comparing current findings with baseline data
C. Calling the rapid response team
D. Documenting in the electronic record
Answer: B
Rationale: Analyzing cues involves interpreting assessment data
and comparing with baseline to determine significance.
Collecting data is cue recognition; calling RRT is action.
Reference: Lewis et al., 5th ed., Ch. 1 – Clinical Judgment Model
in Nursing Practice.
3. Which situation best demonstrates advocacy in medical-
surgical nursing practice?
,A. Administering medications on time
B. Following provider orders without question
C. Questioning a medication dosage that seems unusually high
D. Delegating vital signs to unregulated care personnel
Answer: C
Rationale: Advocacy involves protecting the client’s safety by
questioning unclear or potentially unsafe orders.
Reference: Lewis et al., 5th ed., Ch. 1 – Professional Nursing
Roles and Advocacy.
4. A nurse identifies that a patient’s potassium is critically
elevated. What is the priority nursing action?
A. Document the lab result
B. Notify the health care provider immediately
C. Recheck the value in 4 hours
D. Provide dietary teaching
Answer: B
Rationale: Hyperkalemia is life-threatening due to risk of
dysrhythmias. Immediate notification aligns with patient safety
and early intervention principles.
Reference: Lewis et al., 5th ed., Ch. 1 – Safety and Clinical
Judgment in Acute Care.
, 5. Which statement best reflects evidence-informed nursing
practice?
A. “I do it this way because I was taught that in school.”
B. “This intervention worked for my last patient.”
C. “Research supports early mobilization to reduce
complications.”
D. “The physician prefers this approach.”
Answer: C
Rationale: Evidence-informed practice integrates best current
evidence with clinical expertise and patient preferences.
Reference: Lewis et al., 5th ed., Ch. 1 – Evidence-Informed
Nursing Practice.
6. A newly graduated nurse asks about the difference between
critical thinking and clinical judgment. Which explanation is
most accurate?
A. They are identical concepts.
B. Clinical judgment is the application of critical thinking to
patient care decisions.
C. Critical thinking only applies in emergencies.
D. Clinical judgment is based solely on experience.
Answer: B
Rationale: Critical thinking is a cognitive process; clinical
judgment is its application in real clinical situations.
