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 newly hired medical-surgical nurse is preparing to care for
patients on an adult health unit. The nurse wants to practice in
a way that supports safe, effective, and patient-centered care.
,Question Stem:
Which action best reflects the core competency of safe and
effective healthcare?
Answer Options:
A. Completing all tasks independently to avoid delays
B. Using evidence-based hand hygiene and verification
practices before patient contact
C. Waiting for the physician to identify patient risks before
intervening
D. Limiting patient teaching to reduce information overload
Correct Answer:
B
Detailed Rationale:
Evidence-based hand hygiene and verification practices directly
support patient safety, infection prevention, and reduction of
preventable harm. Core competencies in medical-surgical
nursing emphasize reliable, standardized actions that protect
patients and improve outcomes.
Incorrect Option Analysis:
A: Independent task completion is not the priority if it
bypasses collaboration or safety checks. It reflects speed
over safety.
C: Nurses are responsible for recognizing risks and acting
on them, not waiting passively.
, D: Patient teaching is essential; limiting it may reduce
understanding and self-management.
Nursing Process Linkage: Implementation
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Take Action
Clinical Reasoning Focus: Cue recognition
Difficulty: Easy
Bloom’s Level: Understand
NCLEX Client Needs: Safety and Infection Control
Key Learning Objective: Identify actions that promote safe,
effective, evidence-informed nursing care.
2) MCQ
Clinical Scenario:
A nurse receives report on four assigned patients and must
decide who requires immediate assessment.
Question Stem:
Which patient should the nurse assess first?
Answer Options:
A. A patient requesting pain medication 7/10 after surgery
B. A patient whose blood glucose is 148 mg/dL before lunch
C. A patient with new onset shortness of breath and confusion
D. A patient scheduled for discharge this afternoon
Correct Answer:
C
, Detailed Rationale:
New shortness of breath plus confusion suggests possible acute
deterioration, hypoxemia, or impaired perfusion. This is an
airway-breathing-circulation priority and requires immediate
assessment.
Incorrect Option Analysis:
A: Pain needs treatment, but it is not the most urgent
threat.
B: This glucose level is mildly elevated and does not
indicate immediate instability.
D: Discharge planning is important but not emergent.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Analyze Cues, Prioritize Hypotheses
Clinical Reasoning Focus: Priority setting
Difficulty: Moderate
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation
Key Learning Objective: Prioritize assessment based on signs of
acute clinical deterioration.
3) SATA
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 newly hired medical-surgical nurse is preparing to care for
patients on an adult health unit. The nurse wants to practice in
a way that supports safe, effective, and patient-centered care.
,Question Stem:
Which action best reflects the core competency of safe and
effective healthcare?
Answer Options:
A. Completing all tasks independently to avoid delays
B. Using evidence-based hand hygiene and verification
practices before patient contact
C. Waiting for the physician to identify patient risks before
intervening
D. Limiting patient teaching to reduce information overload
Correct Answer:
B
Detailed Rationale:
Evidence-based hand hygiene and verification practices directly
support patient safety, infection prevention, and reduction of
preventable harm. Core competencies in medical-surgical
nursing emphasize reliable, standardized actions that protect
patients and improve outcomes.
Incorrect Option Analysis:
A: Independent task completion is not the priority if it
bypasses collaboration or safety checks. It reflects speed
over safety.
C: Nurses are responsible for recognizing risks and acting
on them, not waiting passively.
, D: Patient teaching is essential; limiting it may reduce
understanding and self-management.
Nursing Process Linkage: Implementation
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Take Action
Clinical Reasoning Focus: Cue recognition
Difficulty: Easy
Bloom’s Level: Understand
NCLEX Client Needs: Safety and Infection Control
Key Learning Objective: Identify actions that promote safe,
effective, evidence-informed nursing care.
2) MCQ
Clinical Scenario:
A nurse receives report on four assigned patients and must
decide who requires immediate assessment.
Question Stem:
Which patient should the nurse assess first?
Answer Options:
A. A patient requesting pain medication 7/10 after surgery
B. A patient whose blood glucose is 148 mg/dL before lunch
C. A patient with new onset shortness of breath and confusion
D. A patient scheduled for discharge this afternoon
Correct Answer:
C
, Detailed Rationale:
New shortness of breath plus confusion suggests possible acute
deterioration, hypoxemia, or impaired perfusion. This is an
airway-breathing-circulation priority and requires immediate
assessment.
Incorrect Option Analysis:
A: Pain needs treatment, but it is not the most urgent
threat.
B: This glucose level is mildly elevated and does not
indicate immediate instability.
D: Discharge planning is important but not emergent.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Analyze Cues, Prioritize Hypotheses
Clinical Reasoning Focus: Priority setting
Difficulty: Moderate
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation
Key Learning Objective: Prioritize assessment based on signs of
acute clinical deterioration.
3) SATA
