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 on a medical-surgical unit receives shift report on four
patients. During report, the nurse notes that one patient has
new confusion, decreased urine output, and a blood pressure
of 88/54 mm Hg.
Question Stem
,Which action best demonstrates clinical reasoning?
Options
A. Document the findings and continue receiving report.
B. Review the patient's laboratory values after completing
medication administration.
C. Immediately assess the patient and determine whether rapid
intervention is needed.
D. Ask the nursing assistant to recheck the blood pressure in 2
hours.
Correct Answer
C. Immediately assess the patient and determine whether
rapid intervention is needed.
Detailed Rationale
Clinical reasoning involves recognizing cues, analyzing their
significance, prioritizing concerns, and taking action. New
confusion, hypotension, and oliguria may indicate patient
deterioration such as shock or sepsis. Immediate assessment is
necessary to validate findings and determine urgency.
Incorrect Option Analysis
A: Delays assessment of a potentially unstable patient.
B: Laboratory review is important but should not delay direct
patient assessment.
D: Waiting 2 hours could allow significant deterioration.
,Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
Analyze Cues
Prioritize Hypotheses
Clinical Reasoning Focus
Priority Setting
Difficulty
Moderate
Bloom's Level
Analyze
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 explaining the QSEN competencies to a newly hired
graduate nurse.
Question Stem
Which statements reflect core competencies for safe and
effective healthcare? Select all that apply.
Options
A. Patient-centered care
B. Teamwork and collaboration
C. Evidence-based practice
D. Quality improvement
E. Informatics
F. Independent physician decision-making
Correct Answers
A, B, C, D, E
Detailed Rationale
QSEN competencies include patient-centered care, teamwork,
evidence-based practice, quality improvement, safety, and
informatics.
Incorrect Option Analysis
F: Healthcare decisions require interprofessional collaboration,
not independent physician decision-making.
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 on a medical-surgical unit receives shift report on four
patients. During report, the nurse notes that one patient has
new confusion, decreased urine output, and a blood pressure
of 88/54 mm Hg.
Question Stem
,Which action best demonstrates clinical reasoning?
Options
A. Document the findings and continue receiving report.
B. Review the patient's laboratory values after completing
medication administration.
C. Immediately assess the patient and determine whether rapid
intervention is needed.
D. Ask the nursing assistant to recheck the blood pressure in 2
hours.
Correct Answer
C. Immediately assess the patient and determine whether
rapid intervention is needed.
Detailed Rationale
Clinical reasoning involves recognizing cues, analyzing their
significance, prioritizing concerns, and taking action. New
confusion, hypotension, and oliguria may indicate patient
deterioration such as shock or sepsis. Immediate assessment is
necessary to validate findings and determine urgency.
Incorrect Option Analysis
A: Delays assessment of a potentially unstable patient.
B: Laboratory review is important but should not delay direct
patient assessment.
D: Waiting 2 hours could allow significant deterioration.
,Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
Analyze Cues
Prioritize Hypotheses
Clinical Reasoning Focus
Priority Setting
Difficulty
Moderate
Bloom's Level
Analyze
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 explaining the QSEN competencies to a newly hired
graduate nurse.
Question Stem
Which statements reflect core competencies for safe and
effective healthcare? Select all that apply.
Options
A. Patient-centered care
B. Teamwork and collaboration
C. Evidence-based practice
D. Quality improvement
E. Informatics
F. Independent physician decision-making
Correct Answers
A, B, C, D, E
Detailed Rationale
QSEN competencies include patient-centered care, teamwork,
evidence-based practice, quality improvement, safety, and
informatics.
Incorrect Option Analysis
F: Healthcare decisions require interprofessional collaboration,
not independent physician decision-making.
Nursing Process Linkage
