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
Stem: A nurse on a med-surg unit receives a change-of-shift
report that a post-op patient’s oxygen saturation has fallen from
96% to 90% and the patient is more lethargic. The nurse's first
action is to perform a focused assessment. Which aspect of the
focused assessment is the highest priority to determine
immediate safety and oxygenation?
A. Ask the patient about pain level.
,B. Inspect airway patency and listen for breath sounds.
C. Review the surgical note for estimated blood loss.
D. Check the pulse oximeter reading again and reapply sensor.
Correct answer: B
Rationale — Correct (B): Inspecting airway patency and
auscultating breath sounds directly assesses oxygenation and
ventilation and quickly identifies life-threatening problems
(airway obstruction, pneumothorax, atelectasis). According to
Lewis, priority follows ABCs; airway/ breathing issues supersede
other assessments. This step aligns with the NCSBN Clinical
Judgment Model: Recognize the change, Analyze its cause
(airway/ lung), and plan immediate intervention.
Rationale — Incorrect:
A. Pain is important but not the immediate threat to airway/
breathing.
C. Surgical blood loss may affect status but airway/breathing
must be assessed first.
D. Rechecking the pulse oximeter is reasonable, but direct
airway/ lung assessment gives actionable clinical data sooner.
Teaching point: Always assess airway and breath sounds first for
acute oxygenation decline.
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 — Domain of Nursing
Practice
Stem: A newly licensed nurse asks about scope of practice
when a physician requests a nurse-initiated blood glucose check
for a patient with diabetes experiencing lightheadedness.
Which statement reflects the nurse’s correct use of scope and
delegation?
A. “I can perform the glucose check independently because it’s
within nursing assessment.”
B. “I must refuse because only physicians may order bedside
tests.”
C. “I should call charge nurse to reassign this task to a tech.”
D. “I’ll delay because the provider did not enter an electronic
order.”
Correct answer: A
Rationale — Correct (A): Blood glucose measurement is a
nursing assessment/action within the nursing scope and
commonly performed per unit protocol. Lewis emphasizes that
nurses perform assessments and interventions that match their
licensure and competencies. Using clinical judgment, the nurse
can act immediately to gather data that informs further orders
and interventions.
Rationale — Incorrect:
B. Incorrect—bedside point-of-care testing is within nursing
scope when competent and per policy.
C. Delegating to a tech may be appropriate, but the nurse can
perform and should not automatically reassign.
, D. Delaying for an order is unsafe when immediate assessment
is indicated and standing protocols exist.
Teaching point: Perform timely nursing assessments allowed by
scope and unit policy.
Citation: Harding et al. (2023). Ch. 1.
3
Reference: Ch. 1 — Professional Nursing — Standards of
Professional Nursing Practice
Stem: While preparing discharge teaching for a patient with
new heart failure diagnosis, the nurse must ensure patient-
centered care. Which action best demonstrates incorporation of
patient-centered care into the teaching plan?
A. Provide a standardized heart failure packet and ask the
patient to read it at home.
B. Assess the patient’s health literacy, routines, and readiness to
learn before teaching.
C. Schedule a follow-up appointment without involving the
patient in timing.
D. Emphasize medication adherence using medical terminology
to ensure accuracy.
Correct answer: B
Rationale — Correct (B): Lewis highlights patient-centered care
requiring assessment of learning needs, literacy, and readiness;
tailoring education increases comprehension and adherence.
This follows clinical judgment: Recognize patient factors,
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
Stem: A nurse on a med-surg unit receives a change-of-shift
report that a post-op patient’s oxygen saturation has fallen from
96% to 90% and the patient is more lethargic. The nurse's first
action is to perform a focused assessment. Which aspect of the
focused assessment is the highest priority to determine
immediate safety and oxygenation?
A. Ask the patient about pain level.
,B. Inspect airway patency and listen for breath sounds.
C. Review the surgical note for estimated blood loss.
D. Check the pulse oximeter reading again and reapply sensor.
Correct answer: B
Rationale — Correct (B): Inspecting airway patency and
auscultating breath sounds directly assesses oxygenation and
ventilation and quickly identifies life-threatening problems
(airway obstruction, pneumothorax, atelectasis). According to
Lewis, priority follows ABCs; airway/ breathing issues supersede
other assessments. This step aligns with the NCSBN Clinical
Judgment Model: Recognize the change, Analyze its cause
(airway/ lung), and plan immediate intervention.
Rationale — Incorrect:
A. Pain is important but not the immediate threat to airway/
breathing.
C. Surgical blood loss may affect status but airway/breathing
must be assessed first.
D. Rechecking the pulse oximeter is reasonable, but direct
airway/ lung assessment gives actionable clinical data sooner.
Teaching point: Always assess airway and breath sounds first for
acute oxygenation decline.
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 — Domain of Nursing
Practice
Stem: A newly licensed nurse asks about scope of practice
when a physician requests a nurse-initiated blood glucose check
for a patient with diabetes experiencing lightheadedness.
Which statement reflects the nurse’s correct use of scope and
delegation?
A. “I can perform the glucose check independently because it’s
within nursing assessment.”
B. “I must refuse because only physicians may order bedside
tests.”
C. “I should call charge nurse to reassign this task to a tech.”
D. “I’ll delay because the provider did not enter an electronic
order.”
Correct answer: A
Rationale — Correct (A): Blood glucose measurement is a
nursing assessment/action within the nursing scope and
commonly performed per unit protocol. Lewis emphasizes that
nurses perform assessments and interventions that match their
licensure and competencies. Using clinical judgment, the nurse
can act immediately to gather data that informs further orders
and interventions.
Rationale — Incorrect:
B. Incorrect—bedside point-of-care testing is within nursing
scope when competent and per policy.
C. Delegating to a tech may be appropriate, but the nurse can
perform and should not automatically reassign.
, D. Delaying for an order is unsafe when immediate assessment
is indicated and standing protocols exist.
Teaching point: Perform timely nursing assessments allowed by
scope and unit policy.
Citation: Harding et al. (2023). Ch. 1.
3
Reference: Ch. 1 — Professional Nursing — Standards of
Professional Nursing Practice
Stem: While preparing discharge teaching for a patient with
new heart failure diagnosis, the nurse must ensure patient-
centered care. Which action best demonstrates incorporation of
patient-centered care into the teaching plan?
A. Provide a standardized heart failure packet and ask the
patient to read it at home.
B. Assess the patient’s health literacy, routines, and readiness to
learn before teaching.
C. Schedule a follow-up appointment without involving the
patient in timing.
D. Emphasize medication adherence using medical terminology
to ensure accuracy.
Correct answer: B
Rationale — Correct (B): Lewis highlights patient-centered care
requiring assessment of learning needs, literacy, and readiness;
tailoring education increases comprehension and adherence.
This follows clinical judgment: Recognize patient factors,
