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 nurse is caring for a 68-year-old patient admitted with
pneumonia. The patient suddenly becomes confused and has
an oxygen saturation of 84% on room air.
,Question Stem
Which action demonstrates the nurse's use of clinical
reasoning?
A. Document the findings and continue scheduled assessments.
B. Increase oxygen and notify the provider of the patient's
deterioration.
C. Wait 30 minutes and reassess the patient.
D. Delegate reassessment to the nursing assistant.
Correct Answer
B. Increase oxygen and notify the provider of the patient's
deterioration.
Detailed Rationale
Clinical reasoning involves recognizing cues, analyzing their
significance, and taking appropriate action. Acute confusion
and hypoxemia indicate worsening respiratory status and
possible sepsis. Immediate intervention and provider
notification are priorities.
Incorrect Option Analysis
A: Delays treatment and risks respiratory failure.
C: Waiting may result in further deterioration.
D: Assessment and interpretation cannot be delegated.
Nursing Process Linkage
Implementation
,NCJMM Competencies
Recognize Cues
Analyze Cues
Take Action
Clinical Reasoning Focus
Priority Setting
Difficulty
Easy
Bloom's Level
Apply
NCLEX Client Needs
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning to recognize and respond to patient
deterioration.
Question 2 – SATA
Clinical Scenario
A nurse is discussing the QSEN competencies with newly hired
graduate nurses.
Question Stem
, Which statements reflect competencies necessary for safe and
effective healthcare? (Select all that apply.)
A. Patient-centered care
B. Evidence-based practice
C. Quality improvement
D. Informatics
E. Independent physician decision-making
F. Safety
Correct Answers
A, B, C, D, F
Detailed Rationale
Core competencies include:
Patient-centered care
Teamwork and collaboration
Evidence-based practice
Quality improvement
Safety
Informatics
Incorrect Option Analysis
E: Healthcare decisions are collaborative rather than physician
dependent.
Nursing Process Linkage
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 nurse is caring for a 68-year-old patient admitted with
pneumonia. The patient suddenly becomes confused and has
an oxygen saturation of 84% on room air.
,Question Stem
Which action demonstrates the nurse's use of clinical
reasoning?
A. Document the findings and continue scheduled assessments.
B. Increase oxygen and notify the provider of the patient's
deterioration.
C. Wait 30 minutes and reassess the patient.
D. Delegate reassessment to the nursing assistant.
Correct Answer
B. Increase oxygen and notify the provider of the patient's
deterioration.
Detailed Rationale
Clinical reasoning involves recognizing cues, analyzing their
significance, and taking appropriate action. Acute confusion
and hypoxemia indicate worsening respiratory status and
possible sepsis. Immediate intervention and provider
notification are priorities.
Incorrect Option Analysis
A: Delays treatment and risks respiratory failure.
C: Waiting may result in further deterioration.
D: Assessment and interpretation cannot be delegated.
Nursing Process Linkage
Implementation
,NCJMM Competencies
Recognize Cues
Analyze Cues
Take Action
Clinical Reasoning Focus
Priority Setting
Difficulty
Easy
Bloom's Level
Apply
NCLEX Client Needs
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning to recognize and respond to patient
deterioration.
Question 2 – SATA
Clinical Scenario
A nurse is discussing the QSEN competencies with newly hired
graduate nurses.
Question Stem
, Which statements reflect competencies necessary for safe and
effective healthcare? (Select all that apply.)
A. Patient-centered care
B. Evidence-based practice
C. Quality improvement
D. Informatics
E. Independent physician decision-making
F. Safety
Correct Answers
A, B, C, D, F
Detailed Rationale
Core competencies include:
Patient-centered care
Teamwork and collaboration
Evidence-based practice
Quality improvement
Safety
Informatics
Incorrect Option Analysis
E: Healthcare decisions are collaborative rather than physician
dependent.
Nursing Process Linkage
