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 caring for an older adult with heart failure notices
increasing shortness of breath, confusion, and new crackles in
both lung bases.
Question Stem
,Which action demonstrates the nurse's use of clinical
reasoning?
Answer Options
A. Document the findings and continue monitoring
B. Administer oxygen without obtaining additional information
C. Compare current findings with previous assessments and
notify the provider
D. Ask another nurse to assess the patient
Correct Answer
✅ C. Compare current findings with previous assessments and
notify the provider
Detailed Rationale
Clinical reasoning involves recognizing cues, analyzing
information, identifying potential complications, and taking
action. The patient's worsening respiratory status suggests fluid
overload and possible decompensated heart failure requiring
prompt intervention.
Early recognition of deterioration promotes patient safety and
reduces adverse outcomes.
Incorrect Option Analysis
,A.
Incorrect.
Merely documenting delays intervention.
Misconception: Documentation alone fulfills nursing
responsibilities.
Safety implication: Progression to respiratory failure.
B.
Incorrect.
Oxygen may be indicated, but assessment and provider
communication are necessary.
Misconception: Treat symptoms before determining cause.
D.
Incorrect.
Seeking assistance is appropriate but should not delay nursing
action.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
, Analyze Cues
Take Action
Clinical Reasoning Focus
Cue Recognition
Difficulty
Moderate
Bloom Level
Analyze
NCLEX Category
Physiological Adaptation
Learning Objective
Apply clinical reasoning to recognize patient deterioration.
Question 2 – SATA
Clinical Scenario
A nurse is discussing evidence-based practice (EBP) with a
newly hired graduate nurse.
Question Stem
Which statements accurately describe evidence-based
practice?
Answer Choices
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 caring for an older adult with heart failure notices
increasing shortness of breath, confusion, and new crackles in
both lung bases.
Question Stem
,Which action demonstrates the nurse's use of clinical
reasoning?
Answer Options
A. Document the findings and continue monitoring
B. Administer oxygen without obtaining additional information
C. Compare current findings with previous assessments and
notify the provider
D. Ask another nurse to assess the patient
Correct Answer
✅ C. Compare current findings with previous assessments and
notify the provider
Detailed Rationale
Clinical reasoning involves recognizing cues, analyzing
information, identifying potential complications, and taking
action. The patient's worsening respiratory status suggests fluid
overload and possible decompensated heart failure requiring
prompt intervention.
Early recognition of deterioration promotes patient safety and
reduces adverse outcomes.
Incorrect Option Analysis
,A.
Incorrect.
Merely documenting delays intervention.
Misconception: Documentation alone fulfills nursing
responsibilities.
Safety implication: Progression to respiratory failure.
B.
Incorrect.
Oxygen may be indicated, but assessment and provider
communication are necessary.
Misconception: Treat symptoms before determining cause.
D.
Incorrect.
Seeking assistance is appropriate but should not delay nursing
action.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
, Analyze Cues
Take Action
Clinical Reasoning Focus
Cue Recognition
Difficulty
Moderate
Bloom Level
Analyze
NCLEX Category
Physiological Adaptation
Learning Objective
Apply clinical reasoning to recognize patient deterioration.
Question 2 – SATA
Clinical Scenario
A nurse is discussing evidence-based practice (EBP) with a
newly hired graduate nurse.
Question Stem
Which statements accurately describe evidence-based
practice?
Answer Choices
