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
Q1
Reference: Ch. 1 — Professional Nursing Practice — Definitions
of Nursing
Stem: A nurse entering a post-op patient’s room finds the
patient anxious, pale, and reporting chest pressure. Vitals show
HR 110, BP 90/56, and SpO₂ 94% on room air. Which nursing
action best reflects the definition of nursing as described by
Lewis — prioritizing human response and immediate patient
safety?
A. Sit with the patient and provide reassurance while
,documenting the findings.
B. Ask the unit clerk to notify the surgeon and continue
monitoring vitals every 30 minutes.
C. Perform focused assessment, administer oxygen per
protocol, and notify the provider immediately.
D. Call the patient's family to inform them of the change and
request presence at bedside.
Correct Answer: C
Rationale — Correct: This action prioritizes rapid physiologic
assessment and immediate intervention for a potentially
unstable cardiovascular event, aligning with Lewis’s view of
nursing as addressing human responses to health changes. It
follows clinical judgment: recognize abnormal findings, analyze
risk, plan oxygen and notify provider, and intervene promptly.
This response is patient-centered and safety focused.
Rationale — A: Reassurance alone is insufficient for
hypotension and chest pressure; it delays urgent assessment
and intervention.
Rationale — B: Delaying notification and infrequent monitoring
risks deterioration in a potentially unstable patient.
Rationale — D: Family notification is lower priority than
immediate assessment/intervention for potential hemodynamic
compromise.
Teaching Point: Prioritize focused assessment and immediate
interventions for unstable physiologic changes.
Citation: Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C.
(2023). Lewis’s Medical-Surgical Nursing (12th Ed.). Ch. 1.
,Q2
Reference: Ch. 1 — Professional Nursing Practice — Standards
of Professional Nursing Practice
Stem: On change of shift, a nurse notices a colleague charted
PRN morphine as given but there is no wasting documentation
and the patient reports continued severe pain. According to
professional standards, what is the nurse’s best immediate
action?
A. Confront the colleague about incomplete documentation
during break time.
B. Reassess the patient’s pain, check the MAR and wasted
medication record, and report discrepancy to nurse manager.
C. Administer an alternative analgesic without documenting the
previous dose.
D. Ask the patient to rate pain again and leave a note to follow
up tomorrow.
Correct Answer: B
Rationale — Correct: Lewis emphasizes standards including
accountability and accurate documentation. Reassessing the
patient, verifying medication records, and reporting
discrepancies protects patient safety and addresses potential
medication error or diversion. This follows CJM: recognize a
problem, analyze evidence, plan to escalate, and intervene to
ensure safety.
Rationale — A: Private confrontation without verification and
, delay risks patient harm and fails to follow proper reporting
channels.
Rationale — C: Administering another analgesic without
clarifying prior dose risks overdose and violates medication
safety standards.
Rationale — D: Postponing action fails to address immediate
safety concerns and deviates from accountability standards.
Teaching Point: Verify medication records and report
discrepancies immediately to ensure safe pain management.
Citation: Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C.
(2023). Lewis’s Medical-Surgical Nursing (12th Ed.). Ch. 1.
Q3
Reference: Ch. 1 — Professional Nursing Practice — Domain of
Nursing Practice
Stem: A nurse is preparing education for a patient newly
diagnosed with type 2 diabetes; the patient is illiterate and
speaks limited English. Which plan best reflects the nursing
domain of practice focused on holistic, culturally competent
care?
A. Provide a standard written teaching packet and ask family to
translate.
B. Use professional interpreter services, teach with teach-back,
and arrange community resources with visual aids.
C. Show a brief video in English and schedule a follow-up
appointment in two weeks.
ASSESSMENT AND MANAGEMENT OF
CLINICAL PROBLEMS, SINGLE VOLUME
12TH EDITION
• AUTHOR(S)MARIANN M. HARDING;
JEFFREY KWONG; DEBRA HAGLER;
COURTNEY REINISCH
TEST BANK
Q1
Reference: Ch. 1 — Professional Nursing Practice — Definitions
of Nursing
Stem: A nurse entering a post-op patient’s room finds the
patient anxious, pale, and reporting chest pressure. Vitals show
HR 110, BP 90/56, and SpO₂ 94% on room air. Which nursing
action best reflects the definition of nursing as described by
Lewis — prioritizing human response and immediate patient
safety?
A. Sit with the patient and provide reassurance while
,documenting the findings.
B. Ask the unit clerk to notify the surgeon and continue
monitoring vitals every 30 minutes.
C. Perform focused assessment, administer oxygen per
protocol, and notify the provider immediately.
D. Call the patient's family to inform them of the change and
request presence at bedside.
Correct Answer: C
Rationale — Correct: This action prioritizes rapid physiologic
assessment and immediate intervention for a potentially
unstable cardiovascular event, aligning with Lewis’s view of
nursing as addressing human responses to health changes. It
follows clinical judgment: recognize abnormal findings, analyze
risk, plan oxygen and notify provider, and intervene promptly.
This response is patient-centered and safety focused.
Rationale — A: Reassurance alone is insufficient for
hypotension and chest pressure; it delays urgent assessment
and intervention.
Rationale — B: Delaying notification and infrequent monitoring
risks deterioration in a potentially unstable patient.
Rationale — D: Family notification is lower priority than
immediate assessment/intervention for potential hemodynamic
compromise.
Teaching Point: Prioritize focused assessment and immediate
interventions for unstable physiologic changes.
Citation: Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C.
(2023). Lewis’s Medical-Surgical Nursing (12th Ed.). Ch. 1.
,Q2
Reference: Ch. 1 — Professional Nursing Practice — Standards
of Professional Nursing Practice
Stem: On change of shift, a nurse notices a colleague charted
PRN morphine as given but there is no wasting documentation
and the patient reports continued severe pain. According to
professional standards, what is the nurse’s best immediate
action?
A. Confront the colleague about incomplete documentation
during break time.
B. Reassess the patient’s pain, check the MAR and wasted
medication record, and report discrepancy to nurse manager.
C. Administer an alternative analgesic without documenting the
previous dose.
D. Ask the patient to rate pain again and leave a note to follow
up tomorrow.
Correct Answer: B
Rationale — Correct: Lewis emphasizes standards including
accountability and accurate documentation. Reassessing the
patient, verifying medication records, and reporting
discrepancies protects patient safety and addresses potential
medication error or diversion. This follows CJM: recognize a
problem, analyze evidence, plan to escalate, and intervene to
ensure safety.
Rationale — A: Private confrontation without verification and
, delay risks patient harm and fails to follow proper reporting
channels.
Rationale — C: Administering another analgesic without
clarifying prior dose risks overdose and violates medication
safety standards.
Rationale — D: Postponing action fails to address immediate
safety concerns and deviates from accountability standards.
Teaching Point: Verify medication records and report
discrepancies immediately to ensure safe pain management.
Citation: Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C.
(2023). Lewis’s Medical-Surgical Nursing (12th Ed.). Ch. 1.
Q3
Reference: Ch. 1 — Professional Nursing Practice — Domain of
Nursing Practice
Stem: A nurse is preparing education for a patient newly
diagnosed with type 2 diabetes; the patient is illiterate and
speaks limited English. Which plan best reflects the nursing
domain of practice focused on holistic, culturally competent
care?
A. Provide a standard written teaching packet and ask family to
translate.
B. Use professional interpreter services, teach with teach-back,
and arrange community resources with visual aids.
C. Show a brief video in English and schedule a follow-up
appointment in two weeks.
