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 Practice — Domain of
Nursing Practice
Stem: A newly hired med-surg nurse is caring for a
postoperative patient with increasing confusion and
tachycardia. The nurse must choose the most appropriate
immediate action while remaining within the nursing domain of
practice. Which action should the nurse take first?
A. Call the surgeon and request new orders for a head CT.
,B. Conduct a focused assessment of airway, breathing,
circulation, and mental status; notify the rapid response team if
unstable.
C. Increase the rate of the prescribed IV fluid to improve
perfusion.
D. Document findings in the electronic health record and check
again in one hour.
Correct Answer: B
Rationales — Correct: B follows Lewis’s priority framework
(ABC + neuro): perform a focused assessment to recognize
instability (Recognize/Analyze in NCSBN-CJM) and escalate care
immediately. It’s within the nursing domain to assess and
activate rapid response when deterioration is suspected. This
action prioritizes immediate safety and guides subsequent
interventions.
Incorrect A: Calling the surgeon before assessing delays
recognition and may be outside immediate nursing priorities;
assessment directs whether urgent imaging or surgical
notification is needed.
Incorrect C: Increasing IV rate without assessment or orders
risks fluid overload or masking the underlying cause and is not
an autonomous nursing action.
Incorrect D: Delayed documentation and waiting may allow
deterioration; immediate assessment and escalation are higher
priority.
Teaching Point: Use ABC + neuro to assess and activate rapid
response for acute deterioration.
,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 Practice — Definitions
of Nursing
Stem: A nurse on a med-surg unit is delegating tasks to a
nursing assistant for a group of stable patients. Which
delegated task best reflects appropriate use of nursing
definition and scope?
A. Ask the assistant to perform a focused skin assessment and
report findings.
B. Ask the assistant to administer scheduled oral pain
medication.
C. Ask the assistant to teach the patient how to use incentive
spirometry after lung surgery.
D. Ask the assistant to change the central line dressing for a
patient receiving TPN.
Correct Answer: A
Rationales — Correct: A is appropriate delegation: a nursing
assistant can perform basic assessments (skin checks) and
report objective findings; the nurse retains responsibility for
interpretation and clinical decisions (Analyze/Plan). This
matches Lewis’s scope and delegation guidance.
Incorrect B: Medication administration is a licensed nursing
responsibility and cannot be delegated to unlicensed personnel.
, Incorrect C: Teaching about post-op respiratory exercises
requires nursing assessment, teaching skills, and clinical
judgment and should not be delegated.
Incorrect D: Central line dressing changes are sterile, require
licensed nursing competency and policies; delegating risks
patient safety.
Teaching Point: Delegate data collection tasks; RN retains
interpretation and teaching responsibilities.
Citation: Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C.
(2023). Lewis’s Medical-Surgical Nursing (12th Ed.). Ch. 1.
3
Reference: Ch. 1 — Professional Nursing Practice — Nursing’s
View of Humanity
Stem: A patient with chronic COPD expresses frustration and
hopelessness about progressive limitations. As the nurse plans
care grounded in Lewis’s holistic view, which nursing response
best integrates humanity, dignity, and clinical judgment?
A. Encourage the patient to accept discharge and reduce clinic
follow-up appointments.
B. Provide realistic education about self-management, involve
caregiver support, and set attainable activity goals.
C. Refer the patient to a pulmonologist and defer all
psychosocial support to social work.
D. Offer reassurance that the disease is not serious and
symptoms will improve without changes.
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 Practice — Domain of
Nursing Practice
Stem: A newly hired med-surg nurse is caring for a
postoperative patient with increasing confusion and
tachycardia. The nurse must choose the most appropriate
immediate action while remaining within the nursing domain of
practice. Which action should the nurse take first?
A. Call the surgeon and request new orders for a head CT.
,B. Conduct a focused assessment of airway, breathing,
circulation, and mental status; notify the rapid response team if
unstable.
C. Increase the rate of the prescribed IV fluid to improve
perfusion.
D. Document findings in the electronic health record and check
again in one hour.
Correct Answer: B
Rationales — Correct: B follows Lewis’s priority framework
(ABC + neuro): perform a focused assessment to recognize
instability (Recognize/Analyze in NCSBN-CJM) and escalate care
immediately. It’s within the nursing domain to assess and
activate rapid response when deterioration is suspected. This
action prioritizes immediate safety and guides subsequent
interventions.
Incorrect A: Calling the surgeon before assessing delays
recognition and may be outside immediate nursing priorities;
assessment directs whether urgent imaging or surgical
notification is needed.
Incorrect C: Increasing IV rate without assessment or orders
risks fluid overload or masking the underlying cause and is not
an autonomous nursing action.
Incorrect D: Delayed documentation and waiting may allow
deterioration; immediate assessment and escalation are higher
priority.
Teaching Point: Use ABC + neuro to assess and activate rapid
response for acute deterioration.
,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 Practice — Definitions
of Nursing
Stem: A nurse on a med-surg unit is delegating tasks to a
nursing assistant for a group of stable patients. Which
delegated task best reflects appropriate use of nursing
definition and scope?
A. Ask the assistant to perform a focused skin assessment and
report findings.
B. Ask the assistant to administer scheduled oral pain
medication.
C. Ask the assistant to teach the patient how to use incentive
spirometry after lung surgery.
D. Ask the assistant to change the central line dressing for a
patient receiving TPN.
Correct Answer: A
Rationales — Correct: A is appropriate delegation: a nursing
assistant can perform basic assessments (skin checks) and
report objective findings; the nurse retains responsibility for
interpretation and clinical decisions (Analyze/Plan). This
matches Lewis’s scope and delegation guidance.
Incorrect B: Medication administration is a licensed nursing
responsibility and cannot be delegated to unlicensed personnel.
, Incorrect C: Teaching about post-op respiratory exercises
requires nursing assessment, teaching skills, and clinical
judgment and should not be delegated.
Incorrect D: Central line dressing changes are sterile, require
licensed nursing competency and policies; delegating risks
patient safety.
Teaching Point: Delegate data collection tasks; RN retains
interpretation and teaching responsibilities.
Citation: Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C.
(2023). Lewis’s Medical-Surgical Nursing (12th Ed.). Ch. 1.
3
Reference: Ch. 1 — Professional Nursing Practice — Nursing’s
View of Humanity
Stem: A patient with chronic COPD expresses frustration and
hopelessness about progressive limitations. As the nurse plans
care grounded in Lewis’s holistic view, which nursing response
best integrates humanity, dignity, and clinical judgment?
A. Encourage the patient to accept discharge and reduce clinic
follow-up appointments.
B. Provide realistic education about self-management, involve
caregiver support, and set attainable activity goals.
C. Refer the patient to a pulmonologist and defer all
psychosocial support to social work.
D. Offer reassurance that the disease is not serious and
symptoms will improve without changes.
