LEMONE AND BURKE'S MEDICAL-
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
1. MCQ
Clinical Scenario: A postoperative adult patient is on day 1 after
abdominal surgery. During rounds, the nurse notes the patient
is restless, slightly confused, has a respiratory rate of 28/min,
,oxygen saturation of 91% on 2 L/min oxygen, and a heart rate
of 118/min.
Stem: Which patient should the nurse assess first?
Answer Options:
A. The patient reporting incisional pain of 7/10 after receiving
PRN analgesic 30 minutes ago
B. The patient who is stable and waiting for discharge teaching
C. The postoperative patient with new confusion, tachypnea,
tachycardia, and low oxygen saturation
D. The patient asking for more information about the diet order
Correct Answer: C
Detailed Rationale:
New confusion plus tachypnea, tachycardia, and low oxygen
saturation indicate possible acute deterioration affecting
oxygenation and perfusion. The nurse must prioritize the
patient with the most unstable ABC-related findings. The pain
report, discharge questions, and diet questions are important
but are not as urgent.
Incorrect Option Analysis:
A is incorrect because pain needs treatment, but it is not as
immediately threatening as altered mentation and hypoxemia.
B is incorrect because this patient is stable.
D is incorrect because education can wait until urgent
physiologic concerns are addressed.
Nursing Process Linkage: Assessment
,Clinical Judgment Competencies: Recognize Cues, Analyze
Cues, Prioritize Hypotheses
Clinical Reasoning Focus: Priority Setting
Difficulty: Moderate
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify cues of acute deterioration
and prioritize the most unstable patient.
2. SATA
Clinical Scenario: A nurse is preparing for shift change on a
busy medical-surgical unit.
Stem: Which actions reflect core competencies for safe and
effective healthcare? Select all that apply.
Answer Options:
A. Verify the patient’s identity using two identifiers before
medication administration
B. Use SBAR during handoff communication
C. Document all assessments at the end of the shift to avoid
interrupting patient care
D. Perform an independent double-check for insulin
E. Share a password with a coworker so charting can be
completed faster
, Correct Answers: A, B, D
Detailed Rationale:
Two identifiers, structured handoff communication, and
independent double-checks for high-alert medications are all
core safety competencies. These actions reduce preventable
harm, support communication, and improve reliability of care.
Incorrect Option Analysis:
C is incorrect because delayed documentation increases risk of
omissions and inaccurate charting.
E is incorrect because password sharing violates privacy,
security, and professional standards.
Nursing Process Linkage: Implementation
Clinical Judgment Competencies: Take Action, Evaluate
Outcomes
Clinical Reasoning Focus: Safety Behavior Recognition
Difficulty: Easy
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Safety and Infection Control
Key Learning Objective: Recognize behaviors that support safe
and effective care delivery.
3. MCQ
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
1. MCQ
Clinical Scenario: A postoperative adult patient is on day 1 after
abdominal surgery. During rounds, the nurse notes the patient
is restless, slightly confused, has a respiratory rate of 28/min,
,oxygen saturation of 91% on 2 L/min oxygen, and a heart rate
of 118/min.
Stem: Which patient should the nurse assess first?
Answer Options:
A. The patient reporting incisional pain of 7/10 after receiving
PRN analgesic 30 minutes ago
B. The patient who is stable and waiting for discharge teaching
C. The postoperative patient with new confusion, tachypnea,
tachycardia, and low oxygen saturation
D. The patient asking for more information about the diet order
Correct Answer: C
Detailed Rationale:
New confusion plus tachypnea, tachycardia, and low oxygen
saturation indicate possible acute deterioration affecting
oxygenation and perfusion. The nurse must prioritize the
patient with the most unstable ABC-related findings. The pain
report, discharge questions, and diet questions are important
but are not as urgent.
Incorrect Option Analysis:
A is incorrect because pain needs treatment, but it is not as
immediately threatening as altered mentation and hypoxemia.
B is incorrect because this patient is stable.
D is incorrect because education can wait until urgent
physiologic concerns are addressed.
Nursing Process Linkage: Assessment
,Clinical Judgment Competencies: Recognize Cues, Analyze
Cues, Prioritize Hypotheses
Clinical Reasoning Focus: Priority Setting
Difficulty: Moderate
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify cues of acute deterioration
and prioritize the most unstable patient.
2. SATA
Clinical Scenario: A nurse is preparing for shift change on a
busy medical-surgical unit.
Stem: Which actions reflect core competencies for safe and
effective healthcare? Select all that apply.
Answer Options:
A. Verify the patient’s identity using two identifiers before
medication administration
B. Use SBAR during handoff communication
C. Document all assessments at the end of the shift to avoid
interrupting patient care
D. Perform an independent double-check for insulin
E. Share a password with a coworker so charting can be
completed faster
, Correct Answers: A, B, D
Detailed Rationale:
Two identifiers, structured handoff communication, and
independent double-checks for high-alert medications are all
core safety competencies. These actions reduce preventable
harm, support communication, and improve reliability of care.
Incorrect Option Analysis:
C is incorrect because delayed documentation increases risk of
omissions and inaccurate charting.
E is incorrect because password sharing violates privacy,
security, and professional standards.
Nursing Process Linkage: Implementation
Clinical Judgment Competencies: Take Action, Evaluate
Outcomes
Clinical Reasoning Focus: Safety Behavior Recognition
Difficulty: Easy
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Safety and Infection Control
Key Learning Objective: Recognize behaviors that support safe
and effective care delivery.
3. MCQ
