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
Question 1 (MCQ)
Clinical Scenario:
A 64-year-old patient is 2 hours post-op after abdominal
surgery. The nurse notes pale skin, cool clammy extremities,
,heart rate 124/min, blood pressure 86/50 mm Hg, and a
surgical dressing that is saturated with blood.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Recheck the vital signs in 30 minutes
B. Activate the rapid response system and begin focused
assessment for hemorrhage
C. Administer the prescribed opioid for pain
D. Encourage the patient to ambulate to prevent complications
Correct Answer:
B
Detailed Rationale:
The patient has cues consistent with acute blood loss and
shock. The nurse should act immediately by activating rapid
response and performing a focused assessment while preparing
for emergency intervention. This reflects patient safety, early
recognition of deterioration, and clinical judgment.
Incorrect Option Analysis:
A: Incorrect because waiting delays treatment in a
potentially unstable patient.
C: Incorrect because pain management is not the priority
over circulation compromise.
, D: Incorrect because ambulation is unsafe during
hemodynamic instability.
Nursing Process Linkage:
Implementation
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Prioritize Hypotheses; Take Action
Clinical Reasoning Focus:
Priority setting
Difficulty Level:
Difficult
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Prioritize immediate nursing action when cues indicate acute
instability.
Question 2 (SATA)
Clinical Scenario:
A patient with limited English proficiency is admitted for chest
pain. The patient’s adult daughter offers to interpret. The nurse
wants to complete a patient-centered assessment.
, Question Stem:
Which actions demonstrate patient-centered care and safe
communication? Select all that apply.
Answer Options:
A. Use a professional medical interpreter
B. Rely on the daughter for all translation to save time
C. Ask the patient about their preferred name, concerns, and
goals
D. Use teach-back after providing instructions
E. Discuss diagnosis details in the hallway because the patient is
already admitted
Correct Answers:
A, C, D
Detailed Rationale:
Professional interpreters support accuracy and privacy. Asking
the patient about preferences and concerns supports patient-
centered care. Teach-back confirms understanding and helps
prevent errors.
Incorrect Option Analysis:
B: Incorrect because family members may omit or alter
information and can compromise privacy.
E: Incorrect because private information should not be
discussed in public areas.
Nursing Process Linkage:
Assessment
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
Question 1 (MCQ)
Clinical Scenario:
A 64-year-old patient is 2 hours post-op after abdominal
surgery. The nurse notes pale skin, cool clammy extremities,
,heart rate 124/min, blood pressure 86/50 mm Hg, and a
surgical dressing that is saturated with blood.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Recheck the vital signs in 30 minutes
B. Activate the rapid response system and begin focused
assessment for hemorrhage
C. Administer the prescribed opioid for pain
D. Encourage the patient to ambulate to prevent complications
Correct Answer:
B
Detailed Rationale:
The patient has cues consistent with acute blood loss and
shock. The nurse should act immediately by activating rapid
response and performing a focused assessment while preparing
for emergency intervention. This reflects patient safety, early
recognition of deterioration, and clinical judgment.
Incorrect Option Analysis:
A: Incorrect because waiting delays treatment in a
potentially unstable patient.
C: Incorrect because pain management is not the priority
over circulation compromise.
, D: Incorrect because ambulation is unsafe during
hemodynamic instability.
Nursing Process Linkage:
Implementation
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Prioritize Hypotheses; Take Action
Clinical Reasoning Focus:
Priority setting
Difficulty Level:
Difficult
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Prioritize immediate nursing action when cues indicate acute
instability.
Question 2 (SATA)
Clinical Scenario:
A patient with limited English proficiency is admitted for chest
pain. The patient’s adult daughter offers to interpret. The nurse
wants to complete a patient-centered assessment.
, Question Stem:
Which actions demonstrate patient-centered care and safe
communication? Select all that apply.
Answer Options:
A. Use a professional medical interpreter
B. Rely on the daughter for all translation to save time
C. Ask the patient about their preferred name, concerns, and
goals
D. Use teach-back after providing instructions
E. Discuss diagnosis details in the hallway because the patient is
already admitted
Correct Answers:
A, C, D
Detailed Rationale:
Professional interpreters support accuracy and privacy. Asking
the patient about preferences and concerns supports patient-
centered care. Teach-back confirms understanding and helps
prevent errors.
Incorrect Option Analysis:
B: Incorrect because family members may omit or alter
information and can compromise privacy.
E: Incorrect because private information should not be
discussed in public areas.
Nursing Process Linkage:
Assessment
