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 begins a shift caring for a 72-year-old patient admitted
with pneumonia. During assessment, the nurse notes increasing
respiratory rate, new confusion, and oxygen saturation
declining from 95% to 89%.
,Question Stem
Which nursing action best demonstrates clinical reasoning?
Options
A. Document the findings and continue routine assessments.
B. Compare the findings with previous data and notify the
provider of deterioration.
C. Administer prescribed antibiotics early without assessment.
D. Wait until the next scheduled vital sign assessment.
Correct Answer
B
Detailed Rationale
Clinical reasoning requires recognizing significant cues,
comparing them with baseline data, interpreting their meaning,
and acting appropriately. New confusion, tachypnea, and
declining oxygen saturation suggest worsening oxygenation and
possible sepsis. Prompt communication facilitates early
intervention and improves outcomes.
Incorrect Option Analysis
A: Delays response to deterioration.
C: Medication administration alone does not address
assessment findings.
D: Waiting may allow further deterioration.
Nursing Process Linkage
,Assessment
NCJMM Competencies
Recognize Cues; Analyze Cues; Take Action
Clinical Reasoning Focus
Data Interpretation
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Category
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning to identify and respond to patient
deterioration.
Question 2 (MCQ)
Clinical Scenario
A nurse is explaining evidence-based practice (EBP) to a newly
hired graduate nurse.
Question Stem
Which statement best describes evidence-based practice?
, Options
A. Using physician preferences to guide care
B. Using nursing traditions exclusively
C. Integrating best research evidence, clinical expertise, and
patient preferences
D. Following hospital policies regardless of outcomes
Correct Answer
C
Detailed Rationale
EBP combines current best evidence, clinician expertise, and
patient values to support safe, effective, patient-centered care.
Incorrect Option Analysis
A: Incomplete; excludes evidence and patient preferences.
B: Tradition alone may not be supported by evidence.
D: Policies should be evidence-informed but not blindly
followed.
Nursing Process Linkage
Planning
NCJMM Competencies
Generate Solutions
Clinical Reasoning Focus
Decision-Making
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 begins a shift caring for a 72-year-old patient admitted
with pneumonia. During assessment, the nurse notes increasing
respiratory rate, new confusion, and oxygen saturation
declining from 95% to 89%.
,Question Stem
Which nursing action best demonstrates clinical reasoning?
Options
A. Document the findings and continue routine assessments.
B. Compare the findings with previous data and notify the
provider of deterioration.
C. Administer prescribed antibiotics early without assessment.
D. Wait until the next scheduled vital sign assessment.
Correct Answer
B
Detailed Rationale
Clinical reasoning requires recognizing significant cues,
comparing them with baseline data, interpreting their meaning,
and acting appropriately. New confusion, tachypnea, and
declining oxygen saturation suggest worsening oxygenation and
possible sepsis. Prompt communication facilitates early
intervention and improves outcomes.
Incorrect Option Analysis
A: Delays response to deterioration.
C: Medication administration alone does not address
assessment findings.
D: Waiting may allow further deterioration.
Nursing Process Linkage
,Assessment
NCJMM Competencies
Recognize Cues; Analyze Cues; Take Action
Clinical Reasoning Focus
Data Interpretation
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Category
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning to identify and respond to patient
deterioration.
Question 2 (MCQ)
Clinical Scenario
A nurse is explaining evidence-based practice (EBP) to a newly
hired graduate nurse.
Question Stem
Which statement best describes evidence-based practice?
, Options
A. Using physician preferences to guide care
B. Using nursing traditions exclusively
C. Integrating best research evidence, clinical expertise, and
patient preferences
D. Following hospital policies regardless of outcomes
Correct Answer
C
Detailed Rationale
EBP combines current best evidence, clinician expertise, and
patient values to support safe, effective, patient-centered care.
Incorrect Option Analysis
A: Incomplete; excludes evidence and patient preferences.
B: Tradition alone may not be supported by evidence.
D: Policies should be evidence-informed but not blindly
followed.
Nursing Process Linkage
Planning
NCJMM Competencies
Generate Solutions
Clinical Reasoning Focus
Decision-Making
