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 on a surgical unit says, “I feel
lightheaded whenever I stand up,” after receiving a new
antihypertensive medication. The nurse notes the blood
pressure is 96/60 mm Hg supine and the heart rate is 104/min.
Question Stem: What should the nurse do first?
,Answer Options:
A. Notify the provider of a suspected adverse reaction
B. Assist the patient back to bed and obtain orthostatic vital
signs
C. Encourage the patient to drink more fluids immediately
D. Reassure the patient that dizziness is expected after
hospitalization
Correct Answer: B
Detailed Rationale: The nurse should first assess the situation
and protect patient safety. Lightheadedness after standing
suggests orthostatic hypotension, which may be related to
fluid status, medications, or autonomic changes. Orthostatic
vital signs help confirm the problem and guide next steps.
Incorrect Option Analysis:
A is premature because the nurse has not yet completed
focused assessment.
C may help later, but fluids should not be encouraged
before assessing cause and safety.
D dismisses a potentially serious change in status and
could increase fall risk.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies: Recognize Cues; Analyze Cues
Clinical Reasoning Focus: Cue Recognition
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
,NCLEX Client Needs Category: Reduction of Risk Potential
Key Learning Objective: Identify and respond to early cues of
physiologic instability using the nursing process.
2. MCQ
Clinical Scenario: A medical-surgical unit wants to reduce
catheter-associated infections.
Question Stem: Which action best reflects evidence-based
practice?
Answer Options:
A. Adopt the intervention that has been used the longest on the
unit
B. Combine current research evidence, clinical expertise, and
patient context
C. Use the intervention recommended by the most senior nurse
only
D. Wait for an infection to occur before changing practice
Correct Answer: B
Detailed Rationale: Evidence-based practice integrates the best
available research, clinical expertise, and the patient’s
preferences and circumstances. This approach improves
quality and safety because it avoids relying on habit, opinion, or
delayed reaction to harm.
Incorrect Option Analysis:
, A reflects tradition, not evidence.
C relies on authority rather than current evidence.
D is unsafe and reactive rather than preventive.
Nursing Process Linkage: Planning
Clinical Judgment Competencies: Prioritize Hypotheses;
Generate Solutions
Clinical Reasoning Focus: Decision-Making
Difficulty Level: Easy
Bloom’s Cognitive Level: Understand
NCLEX Client Needs Category: Management of Care
Key Learning Objective: Explain the core elements of evidence-
based nursing practice.
3. SATA
Clinical Scenario: A nurse is asked to review a wound-care
protocol before the unit adopts it.
Question Stem: Which actions are part of the evidence-based
practice process? Select all that apply.
Answer Options:
A. Formulate a searchable clinical question
B. Search current high-quality evidence
C. Use a single anecdotal success story as proof
D. Appraise validity and applicability
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 on a surgical unit says, “I feel
lightheaded whenever I stand up,” after receiving a new
antihypertensive medication. The nurse notes the blood
pressure is 96/60 mm Hg supine and the heart rate is 104/min.
Question Stem: What should the nurse do first?
,Answer Options:
A. Notify the provider of a suspected adverse reaction
B. Assist the patient back to bed and obtain orthostatic vital
signs
C. Encourage the patient to drink more fluids immediately
D. Reassure the patient that dizziness is expected after
hospitalization
Correct Answer: B
Detailed Rationale: The nurse should first assess the situation
and protect patient safety. Lightheadedness after standing
suggests orthostatic hypotension, which may be related to
fluid status, medications, or autonomic changes. Orthostatic
vital signs help confirm the problem and guide next steps.
Incorrect Option Analysis:
A is premature because the nurse has not yet completed
focused assessment.
C may help later, but fluids should not be encouraged
before assessing cause and safety.
D dismisses a potentially serious change in status and
could increase fall risk.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies: Recognize Cues; Analyze Cues
Clinical Reasoning Focus: Cue Recognition
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
,NCLEX Client Needs Category: Reduction of Risk Potential
Key Learning Objective: Identify and respond to early cues of
physiologic instability using the nursing process.
2. MCQ
Clinical Scenario: A medical-surgical unit wants to reduce
catheter-associated infections.
Question Stem: Which action best reflects evidence-based
practice?
Answer Options:
A. Adopt the intervention that has been used the longest on the
unit
B. Combine current research evidence, clinical expertise, and
patient context
C. Use the intervention recommended by the most senior nurse
only
D. Wait for an infection to occur before changing practice
Correct Answer: B
Detailed Rationale: Evidence-based practice integrates the best
available research, clinical expertise, and the patient’s
preferences and circumstances. This approach improves
quality and safety because it avoids relying on habit, opinion, or
delayed reaction to harm.
Incorrect Option Analysis:
, A reflects tradition, not evidence.
C relies on authority rather than current evidence.
D is unsafe and reactive rather than preventive.
Nursing Process Linkage: Planning
Clinical Judgment Competencies: Prioritize Hypotheses;
Generate Solutions
Clinical Reasoning Focus: Decision-Making
Difficulty Level: Easy
Bloom’s Cognitive Level: Understand
NCLEX Client Needs Category: Management of Care
Key Learning Objective: Explain the core elements of evidence-
based nursing practice.
3. SATA
Clinical Scenario: A nurse is asked to review a wound-care
protocol before the unit adopts it.
Question Stem: Which actions are part of the evidence-based
practice process? Select all that apply.
Answer Options:
A. Formulate a searchable clinical question
B. Search current high-quality evidence
C. Use a single anecdotal success story as proof
D. Appraise validity and applicability
