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)
Type
Multiple-Choice Question (MCQ)
Clinical Scenario
,A nurse begins a shift caring for a 68-year-old patient admitted
with pneumonia. During report, the nurse learns that the
patient's oxygen requirements increased overnight.
Question Stem
Which action best demonstrates the nurse's use of clinical
reasoning during the assessment phase of the nursing process?
Answer Options
A. Administer prescribed antibiotics immediately.
B. Review overnight oxygen trends and assess respiratory
status.
C. Document the previous nurse's findings in the medical
record.
D. Develop discharge teaching materials.
Correct Answer
B. Review overnight oxygen trends and assess respiratory
status.
Detailed Rationale
Clinical reasoning begins with recognizing and gathering
relevant patient cues. An increase in oxygen requirements may
indicate worsening respiratory status, progression of infection,
or impending respiratory failure. The nurse should collect and
analyze current assessment data before making decisions.
,Assessment is the foundation of the nursing process because
accurate data collection guides all subsequent nursing
decisions.
Incorrect Option Analysis
A. Administer prescribed antibiotics immediately
Why incorrect: Treatment is important but should not precede
assessment of current status.
Misconception: Implementation always comes before
reassessment.
Safety implication: Changes in condition may be missed.
C. Document the previous nurse's findings
Why incorrect: Documentation is not a substitute for current
assessment.
Misconception: Prior findings are sufficient.
Safety implication: Current deterioration may go unrecognized.
D. Develop discharge teaching materials
Why incorrect: Discharge planning is not the immediate
priority.
Misconception: Long-term planning should occur before
assessment.
Safety implication: Acute problems may worsen.
, Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
Analyze Cues
Clinical Reasoning Focus
Cue Recognition
Difficulty
Easy
Bloom's Level
Apply
NCLEX Client Needs
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning principles during patient assessment.
Question 2 (MCQ)
Type
Multiple-Choice Question
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)
Type
Multiple-Choice Question (MCQ)
Clinical Scenario
,A nurse begins a shift caring for a 68-year-old patient admitted
with pneumonia. During report, the nurse learns that the
patient's oxygen requirements increased overnight.
Question Stem
Which action best demonstrates the nurse's use of clinical
reasoning during the assessment phase of the nursing process?
Answer Options
A. Administer prescribed antibiotics immediately.
B. Review overnight oxygen trends and assess respiratory
status.
C. Document the previous nurse's findings in the medical
record.
D. Develop discharge teaching materials.
Correct Answer
B. Review overnight oxygen trends and assess respiratory
status.
Detailed Rationale
Clinical reasoning begins with recognizing and gathering
relevant patient cues. An increase in oxygen requirements may
indicate worsening respiratory status, progression of infection,
or impending respiratory failure. The nurse should collect and
analyze current assessment data before making decisions.
,Assessment is the foundation of the nursing process because
accurate data collection guides all subsequent nursing
decisions.
Incorrect Option Analysis
A. Administer prescribed antibiotics immediately
Why incorrect: Treatment is important but should not precede
assessment of current status.
Misconception: Implementation always comes before
reassessment.
Safety implication: Changes in condition may be missed.
C. Document the previous nurse's findings
Why incorrect: Documentation is not a substitute for current
assessment.
Misconception: Prior findings are sufficient.
Safety implication: Current deterioration may go unrecognized.
D. Develop discharge teaching materials
Why incorrect: Discharge planning is not the immediate
priority.
Misconception: Long-term planning should occur before
assessment.
Safety implication: Acute problems may worsen.
, Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
Analyze Cues
Clinical Reasoning Focus
Cue Recognition
Difficulty
Easy
Bloom's Level
Apply
NCLEX Client Needs
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning principles during patient assessment.
Question 2 (MCQ)
Type
Multiple-Choice Question
