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 patient is 6 hours post–abdominal surgery. The nurse notes
BP 90/56 mm Hg, HR 122/min, respirations 22/min, and the
,patient reports dizziness when turning in bed. The incision
dressing is dry, but the patient appears pale and anxious.
Question Stem:
What is the nurse’s best initial action?
Answer Options:
A. Administer the prescribed opioid for pain
B. Reassess the patient’s vital signs and inspect the
incision/drain sites
C. Encourage early ambulation to prevent postoperative
complications
D. Notify the provider immediately without further assessment
Correct Answer:
B. Reassess the patient’s vital signs and inspect the
incision/drain sites
Detailed Rationale:
The patient has cues of possible postoperative bleeding or
hypovolemia. The nurse’s first priority is assessment: confirm
the abnormal findings, evaluate the surgical site and drains, and
look for evidence of concealed blood loss before escalating
care. This supports accurate clinical reasoning and prevents
unnecessary delays or unsafe assumptions.
Incorrect Option Analysis:
A: Pain management is important, but giving opioids first
could worsen hypotension and mask deterioration.
, C: Ambulation is inappropriate in a potentially unstable
patient. This reflects a common misconception that all
postop patients should mobilize immediately.
D: Notification may be needed, but nurse must first gather
focused assessment data unless the patient is crashing.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues
Clinical Reasoning Focus:
Cue Recognition; Data Interpretation
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Recognize early signs of postoperative deterioration and
prioritize focused assessment before escalation.
2) SATA
, Clinical Scenario:
A unit is implementing a central line maintenance bundle to
reduce bloodstream infections.
Question Stem:
Which actions are components of evidence-informed central
line care bundles? Select all that apply.
Answer Options:
A. Perform hand hygiene before handling the line
B. Use chlorhexidine for site antisepsis when indicated by policy
C. Scrub the hub before accessing the line
D. Review daily whether the line is still necessary
E. Replace the dressing only when it becomes visibly soiled
F. Flush the line with any available solution to maintain patency
Correct Answer(s):
A, B, C, D
Detailed Rationale:
Central line care bundles reduce infection risk by combining
several high-reliability practices: hand hygiene, skin antisepsis,
hub disinfection, and daily necessity review. The strength of a
bundle is that each step targets a specific infection pathway
and improves patient safety.
Incorrect Option Analysis:
E: Dressings should be changed according to policy and
integrity, not only when visibly soiled. Waiting too long
increases infection risk.
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 patient is 6 hours post–abdominal surgery. The nurse notes
BP 90/56 mm Hg, HR 122/min, respirations 22/min, and the
,patient reports dizziness when turning in bed. The incision
dressing is dry, but the patient appears pale and anxious.
Question Stem:
What is the nurse’s best initial action?
Answer Options:
A. Administer the prescribed opioid for pain
B. Reassess the patient’s vital signs and inspect the
incision/drain sites
C. Encourage early ambulation to prevent postoperative
complications
D. Notify the provider immediately without further assessment
Correct Answer:
B. Reassess the patient’s vital signs and inspect the
incision/drain sites
Detailed Rationale:
The patient has cues of possible postoperative bleeding or
hypovolemia. The nurse’s first priority is assessment: confirm
the abnormal findings, evaluate the surgical site and drains, and
look for evidence of concealed blood loss before escalating
care. This supports accurate clinical reasoning and prevents
unnecessary delays or unsafe assumptions.
Incorrect Option Analysis:
A: Pain management is important, but giving opioids first
could worsen hypotension and mask deterioration.
, C: Ambulation is inappropriate in a potentially unstable
patient. This reflects a common misconception that all
postop patients should mobilize immediately.
D: Notification may be needed, but nurse must first gather
focused assessment data unless the patient is crashing.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues
Clinical Reasoning Focus:
Cue Recognition; Data Interpretation
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Recognize early signs of postoperative deterioration and
prioritize focused assessment before escalation.
2) SATA
, Clinical Scenario:
A unit is implementing a central line maintenance bundle to
reduce bloodstream infections.
Question Stem:
Which actions are components of evidence-informed central
line care bundles? Select all that apply.
Answer Options:
A. Perform hand hygiene before handling the line
B. Use chlorhexidine for site antisepsis when indicated by policy
C. Scrub the hub before accessing the line
D. Review daily whether the line is still necessary
E. Replace the dressing only when it becomes visibly soiled
F. Flush the line with any available solution to maintain patency
Correct Answer(s):
A, B, C, D
Detailed Rationale:
Central line care bundles reduce infection risk by combining
several high-reliability practices: hand hygiene, skin antisepsis,
hub disinfection, and daily necessity review. The strength of a
bundle is that each step targets a specific infection pathway
and improves patient safety.
Incorrect Option Analysis:
E: Dressings should be changed according to policy and
integrity, not only when visibly soiled. Waiting too long
increases infection risk.
