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 — Standards of
Professional Nursing Practice / Patient-Centered Care
Stem: A newly licensed nurse on a medical unit receives report
on four patients. Which action by the nurse best demonstrates
patient-centered care and priority setting when planning the
first 30 minutes of the shift?
A. Begin morning medications for a stable patient with
hypertension.
,B. Perform an immediate focused respiratory assessment on a
patient reporting new-onset shortness of breath.
C. Complete documentation for a postoperative patient before
entering any patient rooms.
D. Call the unit’s case manager to arrange discharge planning
for a patient scheduled to leave later.
Correct answer: B
Rationales — Correct (3–4 sentences): Performing an
immediate focused respiratory assessment addresses an acute
change (new-onset dyspnea) that may signal deterioration;
Lewis emphasizes recognizing early clinical changes and
prioritizing safety (ABC). This action aligns with patient-centered
care and clinical judgment models: Recognize → Analyze → Plan
→ Intervene → Evaluate. It is the highest priority over routine
tasks because respiratory compromise can rapidly progress.
Rationales — Incorrect:
A. Medication administration for a stable chronic condition is
important but lower priority than evaluating a new acute
symptom.
C. Documentation is necessary but delaying assessment of a
patient with new dyspnea risks harm.
D. Discharge planning is important but not time-sensitive
compared with acute respiratory symptoms.
Teaching point: Acute symptom changes (dyspnea) require
immediate assessment and intervention.
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 — Clinical Judgment /
Nursing Care Plans
Stem: A nurse uses the NCSBN Clinical Judgment Model when a
patient’s blood glucose reads 42 mg/dL on point-of-care testing.
Which immediate nursing action best follows the CJM and
Lewis’s safety frameworks?
A. Recheck the blood glucose in 30 minutes before acting.
B. Give 4 ounces of orange juice orally and recheck the glucose
in 15 minutes.
C. Notify the provider and await orders before giving
carbohydrate.
D. Document the result and continue routine monitoring every
hour.
Correct answer: B
Rationales — Correct: A blood glucose of 42 mg/dL is critical
hypoglycemia needing immediate treatment. Lewis and CJM
prioritize timely, evidence-based interventions: recognize the
problem, analyze risk, plan and intervene (rapid oral
carbohydrate for an alert patient). Acting promptly reduces risk
of seizure or loss of consciousness. Reassessment after 15
minutes follows evaluation step.
Rationales — Incorrect:
A. Waiting 30 minutes risks progression to severe hypoglycemia
— unsafe.
, C. Waiting for provider orders delays an established standing
nursing intervention for hypoglycemia.
D. Documentation without intervention ignores acute
physiologic danger.
Teaching point: Treat hypoglycemia immediately with quick-
acting carbs; reassess in 15 minutes.
Citation: Harding et al. (2023). Ch. 1.
3
Reference: Ch. 1 — Professional Nursing — Delegation and
Assignment / Scope of Practice
Stem: On a med–surg unit, the RN must delegate tasks during
morning care. Which assignment is most appropriate to
delegate to an experienced unlicensed assistive personnel
(UAP) while maintaining safe RN accountability?
A. Teach a newly diagnosed diabetic patient how to use an
insulin pen.
B. Obtain routine vital signs and report a BP of 86/50
immediately.
C. Perform a focused neurovascular assessment of a patient
with a new cast.
D. Administer PRN pain medication via IV push.
Correct answer: B
Rationales — Correct: Delegating routine vital signs to a UAP is
appropriate when the UAP is competent; the RN remains
accountable and must ensure immediate reporting of abnormal
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 — Standards of
Professional Nursing Practice / Patient-Centered Care
Stem: A newly licensed nurse on a medical unit receives report
on four patients. Which action by the nurse best demonstrates
patient-centered care and priority setting when planning the
first 30 minutes of the shift?
A. Begin morning medications for a stable patient with
hypertension.
,B. Perform an immediate focused respiratory assessment on a
patient reporting new-onset shortness of breath.
C. Complete documentation for a postoperative patient before
entering any patient rooms.
D. Call the unit’s case manager to arrange discharge planning
for a patient scheduled to leave later.
Correct answer: B
Rationales — Correct (3–4 sentences): Performing an
immediate focused respiratory assessment addresses an acute
change (new-onset dyspnea) that may signal deterioration;
Lewis emphasizes recognizing early clinical changes and
prioritizing safety (ABC). This action aligns with patient-centered
care and clinical judgment models: Recognize → Analyze → Plan
→ Intervene → Evaluate. It is the highest priority over routine
tasks because respiratory compromise can rapidly progress.
Rationales — Incorrect:
A. Medication administration for a stable chronic condition is
important but lower priority than evaluating a new acute
symptom.
C. Documentation is necessary but delaying assessment of a
patient with new dyspnea risks harm.
D. Discharge planning is important but not time-sensitive
compared with acute respiratory symptoms.
Teaching point: Acute symptom changes (dyspnea) require
immediate assessment and intervention.
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 — Clinical Judgment /
Nursing Care Plans
Stem: A nurse uses the NCSBN Clinical Judgment Model when a
patient’s blood glucose reads 42 mg/dL on point-of-care testing.
Which immediate nursing action best follows the CJM and
Lewis’s safety frameworks?
A. Recheck the blood glucose in 30 minutes before acting.
B. Give 4 ounces of orange juice orally and recheck the glucose
in 15 minutes.
C. Notify the provider and await orders before giving
carbohydrate.
D. Document the result and continue routine monitoring every
hour.
Correct answer: B
Rationales — Correct: A blood glucose of 42 mg/dL is critical
hypoglycemia needing immediate treatment. Lewis and CJM
prioritize timely, evidence-based interventions: recognize the
problem, analyze risk, plan and intervene (rapid oral
carbohydrate for an alert patient). Acting promptly reduces risk
of seizure or loss of consciousness. Reassessment after 15
minutes follows evaluation step.
Rationales — Incorrect:
A. Waiting 30 minutes risks progression to severe hypoglycemia
— unsafe.
, C. Waiting for provider orders delays an established standing
nursing intervention for hypoglycemia.
D. Documentation without intervention ignores acute
physiologic danger.
Teaching point: Treat hypoglycemia immediately with quick-
acting carbs; reassess in 15 minutes.
Citation: Harding et al. (2023). Ch. 1.
3
Reference: Ch. 1 — Professional Nursing — Delegation and
Assignment / Scope of Practice
Stem: On a med–surg unit, the RN must delegate tasks during
morning care. Which assignment is most appropriate to
delegate to an experienced unlicensed assistive personnel
(UAP) while maintaining safe RN accountability?
A. Teach a newly diagnosed diabetic patient how to use an
insulin pen.
B. Obtain routine vital signs and report a BP of 86/50
immediately.
C. Perform a focused neurovascular assessment of a patient
with a new cast.
D. Administer PRN pain medication via IV push.
Correct answer: B
Rationales — Correct: Delegating routine vital signs to a UAP is
appropriate when the UAP is competent; the RN remains
accountable and must ensure immediate reporting of abnormal
