Page 1 of 85
LEWIS'S MEDICAL-SURGICAL NURSING EXAM WITH
VERIFIED ANSWERS DETAILED RATIONALES GRADED A+
Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems — Test
Bank
SECTION 1: PROFESSIONAL NURSING PRACTICE & CONCEPTS OF CARE (Questions 1–25)
1. A nurse asks the patient if pain was relieved after receiving medication. What is the
purpose of the evaluation phase of the nursing process?
A. To determine if interventions have been effective in meeting patient outcomes
B. To document the nursing care plan in the progress notes of the medical record
C. To decide whether the patient's health problems have been completely resolved
D. To establish if the patient agrees that the nursing care provided was satisfactory
Correct Answer: A
Rationale: Evaluation consists of determining whether the desired patient outcomes have been
met and whether the nursing interventions were appropriate. The other responses do not
describe the evaluation phase.
2. The nurse interviews a patient while completing the health history and physical
examination. What is the purpose of the assessment phase of the nursing process?
A. To teach interventions that relieve health problems
B. To use patient data to evaluate patient care outcomes
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C. To obtain data with which to diagnose patient problems
D. To help the patient identify realistic outcomes for health problems
Correct Answer: C
Rationale: During the assessment phase, the nurse gathers information about the patient to
diagnose patient problems. The other responses are examples of the planning, intervention,
and evaluation phases of the nursing process.
3. Which statement by the nurse accurately describes the use of evidence-based practice
(EBP)?
A. "Patient care is based on clinical judgment, experience, and traditions."
B. "Data are analyzed later to show that the patient outcomes are consistently met."
C. "Research from all published articles are used as a guide for planning patient care."
D. "Recommendations are based on research, clinical expertise, and patient preferences."
Correct Answer: D
Rationale: Evidence-based practice (EBP) integrates the best research-based evidence
combined with clinician expertise and consideration of patient preferences. Clinical judgment
based on experience is part of EBP, but decision-making should also incorporate current
research and research-based guidelines.
4. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresis.
Which expected outcome would the nurse select for this patient?
A. Patient has a balanced intake and output.
B. Patient's bedding is kept clean and free of moisture.
C. Patient understands the need for increased fluid intake.
D. Patient's skin remains cool and dry throughout hospitalization.
Correct Answer: A
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Rationale: Balanced intake and output provides measurable data showing resolution of
deficient fluid volume. The other statements would not indicate that the problem of
hypovolemia was resolved.
5. Which statement describes the purpose of the evaluation phase of the nursing process?
A. To document the nursing care plan in the progress notes of the health record
B. To determine if interventions have been effective in meeting patient outcomes
C. To decide whether the patient's health problems have been completely resolved
D. To establish if the patient agrees that the nursing care provided was satisfactory
Correct Answer: B
Rationale: Evaluation consists of determining whether the desired patient outcomes have been
met and whether the nursing interventions were appropriate.
6. Which statement describes the purpose of the assessment phase of the nursing process?
A. To teach interventions that relieve health problems
B. To use patient data to evaluate patient care outcomes
C. To obtain data to diagnose patient strengths and problems
D. To help the patient identify realistic outcomes for health problems
Correct Answer: C
Rationale: During the assessment phase, the nurse gathers information about the patient to
diagnose patient strengths and problems.
7. Which patient care task can be delegated to experienced assistive personnel (AP)?
A. Obtaining the patient's blood pressure and pulse rate after ambulation
B. Checking for the presence of bowel sounds
C. Measuring bedside blood glucose before administering insulin
D. Reinforcing teaching about a 2-gram sodium diet
Correct Answer: A
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Rationale: Obtaining vital signs after ambulation is a non-invasive, routine task that can be
safely delegated to assistive personnel. Checking bowel sounds requires nursing assessment;
measuring blood glucose and administering insulin require a licensed nurse; and reinforcing
teaching requires evaluation of understanding.
8. Which assignment would be outside the scope of practice for an assistive personnel (AP)?
A. Assisting a patient with ambulation to the bathroom
B. Measuring and recording daily weight
C. Checking for the presence of bowel sounds
D. Taking vital signs and reporting abnormal findings
Correct Answer: C
Rationale: Checking for bowel sounds requires nursing assessment and clinical judgment and is
outside the scope of practice for assistive personnel. Ambulation, measuring weight, and taking
vital signs are appropriate tasks for AP.
9. What task can a licensed practical/vocational nurse (LPN/VN) perform?
A. Performing an initial admission assessment
B. Developing the nursing care plan
C. Measuring bedside blood glucose before administering insulin
D. Teaching a patient about a new medication
Correct Answer: C
Rationale: An LPN/VN can measure bedside blood glucose and administer insulin under the
supervision of an RN. Initial assessments, developing care plans, and patient teaching are
responsibilities of the RN.
10. What is the role of a case manager in patient care?
A. Provide direct bedside nursing care
B. Coordinate the services the patient receives in the hospital and at home
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LEWIS'S MEDICAL-SURGICAL NURSING EXAM WITH
VERIFIED ANSWERS DETAILED RATIONALES GRADED A+
Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems — Test
Bank
SECTION 1: PROFESSIONAL NURSING PRACTICE & CONCEPTS OF CARE (Questions 1–25)
1. A nurse asks the patient if pain was relieved after receiving medication. What is the
purpose of the evaluation phase of the nursing process?
A. To determine if interventions have been effective in meeting patient outcomes
B. To document the nursing care plan in the progress notes of the medical record
C. To decide whether the patient's health problems have been completely resolved
D. To establish if the patient agrees that the nursing care provided was satisfactory
Correct Answer: A
Rationale: Evaluation consists of determining whether the desired patient outcomes have been
met and whether the nursing interventions were appropriate. The other responses do not
describe the evaluation phase.
2. The nurse interviews a patient while completing the health history and physical
examination. What is the purpose of the assessment phase of the nursing process?
A. To teach interventions that relieve health problems
B. To use patient data to evaluate patient care outcomes
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,Page 2 of 85
C. To obtain data with which to diagnose patient problems
D. To help the patient identify realistic outcomes for health problems
Correct Answer: C
Rationale: During the assessment phase, the nurse gathers information about the patient to
diagnose patient problems. The other responses are examples of the planning, intervention,
and evaluation phases of the nursing process.
3. Which statement by the nurse accurately describes the use of evidence-based practice
(EBP)?
A. "Patient care is based on clinical judgment, experience, and traditions."
B. "Data are analyzed later to show that the patient outcomes are consistently met."
C. "Research from all published articles are used as a guide for planning patient care."
D. "Recommendations are based on research, clinical expertise, and patient preferences."
Correct Answer: D
Rationale: Evidence-based practice (EBP) integrates the best research-based evidence
combined with clinician expertise and consideration of patient preferences. Clinical judgment
based on experience is part of EBP, but decision-making should also incorporate current
research and research-based guidelines.
4. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresis.
Which expected outcome would the nurse select for this patient?
A. Patient has a balanced intake and output.
B. Patient's bedding is kept clean and free of moisture.
C. Patient understands the need for increased fluid intake.
D. Patient's skin remains cool and dry throughout hospitalization.
Correct Answer: A
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,Page 3 of 85
Rationale: Balanced intake and output provides measurable data showing resolution of
deficient fluid volume. The other statements would not indicate that the problem of
hypovolemia was resolved.
5. Which statement describes the purpose of the evaluation phase of the nursing process?
A. To document the nursing care plan in the progress notes of the health record
B. To determine if interventions have been effective in meeting patient outcomes
C. To decide whether the patient's health problems have been completely resolved
D. To establish if the patient agrees that the nursing care provided was satisfactory
Correct Answer: B
Rationale: Evaluation consists of determining whether the desired patient outcomes have been
met and whether the nursing interventions were appropriate.
6. Which statement describes the purpose of the assessment phase of the nursing process?
A. To teach interventions that relieve health problems
B. To use patient data to evaluate patient care outcomes
C. To obtain data to diagnose patient strengths and problems
D. To help the patient identify realistic outcomes for health problems
Correct Answer: C
Rationale: During the assessment phase, the nurse gathers information about the patient to
diagnose patient strengths and problems.
7. Which patient care task can be delegated to experienced assistive personnel (AP)?
A. Obtaining the patient's blood pressure and pulse rate after ambulation
B. Checking for the presence of bowel sounds
C. Measuring bedside blood glucose before administering insulin
D. Reinforcing teaching about a 2-gram sodium diet
Correct Answer: A
3|Page
, Page 4 of 85
Rationale: Obtaining vital signs after ambulation is a non-invasive, routine task that can be
safely delegated to assistive personnel. Checking bowel sounds requires nursing assessment;
measuring blood glucose and administering insulin require a licensed nurse; and reinforcing
teaching requires evaluation of understanding.
8. Which assignment would be outside the scope of practice for an assistive personnel (AP)?
A. Assisting a patient with ambulation to the bathroom
B. Measuring and recording daily weight
C. Checking for the presence of bowel sounds
D. Taking vital signs and reporting abnormal findings
Correct Answer: C
Rationale: Checking for bowel sounds requires nursing assessment and clinical judgment and is
outside the scope of practice for assistive personnel. Ambulation, measuring weight, and taking
vital signs are appropriate tasks for AP.
9. What task can a licensed practical/vocational nurse (LPN/VN) perform?
A. Performing an initial admission assessment
B. Developing the nursing care plan
C. Measuring bedside blood glucose before administering insulin
D. Teaching a patient about a new medication
Correct Answer: C
Rationale: An LPN/VN can measure bedside blood glucose and administer insulin under the
supervision of an RN. Initial assessments, developing care plans, and patient teaching are
responsibilities of the RN.
10. What is the role of a case manager in patient care?
A. Provide direct bedside nursing care
B. Coordinate the services the patient receives in the hospital and at home
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