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 heart
failure exacerbation. During assessment, the nurse notes
increasing dyspnea, bilateral crackles, and oxygen saturation
declining from 95% to 89%.
Question Stem
,Which action best demonstrates the nurse's use of clinical
reasoning?
Options
A. Document findings and continue the assessment
B. Notify the healthcare provider after completing all assigned
tasks
C. Analyze the assessment findings and initiate appropriate
interventions
D. Wait for additional symptoms before acting
Correct Answer
C. Analyze the assessment findings and initiate appropriate
interventions
Detailed Rationale
Clinical reasoning involves collecting cues, analyzing data,
recognizing deterioration, prioritizing patient needs, and
implementing timely interventions. The patient's worsening
respiratory status suggests fluid overload requiring prompt
action. Delaying intervention may increase risk for respiratory
failure.
Incorrect Option Analysis
A: Fails to address deterioration promptly. Documentation
alone is insufficient.
B: Delays necessary intervention and prioritization.
,D: Waiting may allow further deterioration and compromises
patient safety.
Nursing Process Linkage
Assessment → Analysis
NCJMM Competencies
Recognize Cues
Analyze Cues
Take Action
Clinical Reasoning Focus
Data Interpretation
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Category
Physiological Adaptation
Learning Objective
Apply clinical reasoning principles to recognize and respond to
patient deterioration.
Question 2 (MCQ)
, Clinical Scenario
A nurse is conducting an admission assessment on a patient
with newly diagnosed diabetes mellitus.
Question Stem
Which activity represents the assessment phase of the nursing
process?
Options
A. Developing patient-centered goals
B. Identifying risk for unstable blood glucose
C. Collecting information about diet, medications, and
symptoms
D. Evaluating effectiveness of teaching
Correct Answer
C. Collecting information about diet, medications, and
symptoms
Detailed Rationale
Assessment is the systematic collection of subjective and
objective data used to identify patient needs and guide care
planning.
Incorrect Option Analysis
A: Planning phase.
B: Nursing diagnosis phase.
D: Evaluation phase.
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 heart
failure exacerbation. During assessment, the nurse notes
increasing dyspnea, bilateral crackles, and oxygen saturation
declining from 95% to 89%.
Question Stem
,Which action best demonstrates the nurse's use of clinical
reasoning?
Options
A. Document findings and continue the assessment
B. Notify the healthcare provider after completing all assigned
tasks
C. Analyze the assessment findings and initiate appropriate
interventions
D. Wait for additional symptoms before acting
Correct Answer
C. Analyze the assessment findings and initiate appropriate
interventions
Detailed Rationale
Clinical reasoning involves collecting cues, analyzing data,
recognizing deterioration, prioritizing patient needs, and
implementing timely interventions. The patient's worsening
respiratory status suggests fluid overload requiring prompt
action. Delaying intervention may increase risk for respiratory
failure.
Incorrect Option Analysis
A: Fails to address deterioration promptly. Documentation
alone is insufficient.
B: Delays necessary intervention and prioritization.
,D: Waiting may allow further deterioration and compromises
patient safety.
Nursing Process Linkage
Assessment → Analysis
NCJMM Competencies
Recognize Cues
Analyze Cues
Take Action
Clinical Reasoning Focus
Data Interpretation
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Category
Physiological Adaptation
Learning Objective
Apply clinical reasoning principles to recognize and respond to
patient deterioration.
Question 2 (MCQ)
, Clinical Scenario
A nurse is conducting an admission assessment on a patient
with newly diagnosed diabetes mellitus.
Question Stem
Which activity represents the assessment phase of the nursing
process?
Options
A. Developing patient-centered goals
B. Identifying risk for unstable blood glucose
C. Collecting information about diet, medications, and
symptoms
D. Evaluating effectiveness of teaching
Correct Answer
C. Collecting information about diet, medications, and
symptoms
Detailed Rationale
Assessment is the systematic collection of subjective and
objective data used to identify patient needs and guide care
planning.
Incorrect Option Analysis
A: Planning phase.
B: Nursing diagnosis phase.
D: Evaluation phase.
