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 newly licensed nurse is caring for four adult medical-surgical
patients. During morning rounds, the nurse notices that one
patient who was alert an hour ago is now confused and
restless.
,Question Stem
Which action best demonstrates clinical reasoning and
judgment?
A. Document the behavior change and reassess in 4 hours.
B. Notify the provider immediately without further assessment.
C. Assess oxygen saturation, vital signs, and neurologic status
before determining next actions.
D. Ask the nursing assistant whether the patient has been
confused all morning.
Correct Answer
C. Assess oxygen saturation, vital signs, and neurologic status
before determining next actions.
Detailed Rationale
Clinical reasoning begins with recognizing and analyzing cues.
Acute confusion may indicate hypoxia, infection, stroke,
medication effects, or metabolic disturbances. The nurse
should gather additional assessment data before determining
interventions. This approach supports patient safety and
informed decision-making.
Incorrect Option Analysis
A: Delays assessment of a potentially serious condition.
B: Communication may be necessary later, but additional
assessment is needed first.
, D: Secondary information may be useful but cannot
replace direct assessment.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
Analyze Cues
Clinical Reasoning Focus
Cue Recognition
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Client Needs
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning principles to identify and respond to
patient deterioration.
Question 2 — SATA
Clinical Scenario
, A nurse is discussing the Quality and Safety Education for
Nurses (QSEN) competencies with a group of nursing students.
Question Stem
Which competencies support safe and effective healthcare?
(Select all that apply.)
A. Patient-centered care
B. Teamwork and collaboration
C. Evidence-based practice
D. Quality improvement
E. Informatics
F. Independent physician practice
Correct Answers
A, B, C, D, E
Detailed Rationale
QSEN competencies include patient-centered care, teamwork
and collaboration, evidence-based practice, quality
improvement, safety, and informatics. These competencies
improve healthcare outcomes and reduce errors.
Incorrect Option Analysis
F: Nursing practice emphasizes collaboration rather than
independent physician practice.
Nursing Process Linkage
Planning
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 newly licensed nurse is caring for four adult medical-surgical
patients. During morning rounds, the nurse notices that one
patient who was alert an hour ago is now confused and
restless.
,Question Stem
Which action best demonstrates clinical reasoning and
judgment?
A. Document the behavior change and reassess in 4 hours.
B. Notify the provider immediately without further assessment.
C. Assess oxygen saturation, vital signs, and neurologic status
before determining next actions.
D. Ask the nursing assistant whether the patient has been
confused all morning.
Correct Answer
C. Assess oxygen saturation, vital signs, and neurologic status
before determining next actions.
Detailed Rationale
Clinical reasoning begins with recognizing and analyzing cues.
Acute confusion may indicate hypoxia, infection, stroke,
medication effects, or metabolic disturbances. The nurse
should gather additional assessment data before determining
interventions. This approach supports patient safety and
informed decision-making.
Incorrect Option Analysis
A: Delays assessment of a potentially serious condition.
B: Communication may be necessary later, but additional
assessment is needed first.
, D: Secondary information may be useful but cannot
replace direct assessment.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
Analyze Cues
Clinical Reasoning Focus
Cue Recognition
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Client Needs
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning principles to identify and respond to
patient deterioration.
Question 2 — SATA
Clinical Scenario
, A nurse is discussing the Quality and Safety Education for
Nurses (QSEN) competencies with a group of nursing students.
Question Stem
Which competencies support safe and effective healthcare?
(Select all that apply.)
A. Patient-centered care
B. Teamwork and collaboration
C. Evidence-based practice
D. Quality improvement
E. Informatics
F. Independent physician practice
Correct Answers
A, B, C, D, E
Detailed Rationale
QSEN competencies include patient-centered care, teamwork
and collaboration, evidence-based practice, quality
improvement, safety, and informatics. These competencies
improve healthcare outcomes and reduce errors.
Incorrect Option Analysis
F: Nursing practice emphasizes collaboration rather than
independent physician practice.
Nursing Process Linkage
Planning
