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 new graduate nurse is reviewing a unit practice for central-
line dressing changes. One nurse says, “We have always done it
,this way,” while the current policy references a recent
evidence-based bundle.
Question Stem:
Which action best reflects evidence-based nursing practice?
Answer Options:
A. Continue the long-standing unit routine because it is familiar
to staff
B. Use the practice preferred by the most experienced nurse
C. Compare the current research, facility policy, and patient
factors before choosing the intervention
D. Delay practice changes until an adverse event occurs
Correct Answer:
C
Detailed Rationale:
Evidence-based practice integrates current best research
evidence, clinical expertise, and patient preferences. In med-
surg nursing, safe practice is not based on habit or seniority but
on the best available evidence applied to the individual patient.
Incorrect Option Analysis:
A. Incorrect because tradition alone is not evidence; this may
preserve outdated care.
B. Incorrect because experience is helpful but cannot replace
evidence.
D. Incorrect because waiting for harm is unsafe and unethical.
,Nursing Process Linkage:
Planning
NCJMM Competencies:
Recognize Cues, Analyze Cues, Generate Solutions
Clinical Reasoning Focus:
Decision-Making
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Management of Care
Key Learning Objective:
Select evidence-informed nursing actions when unit tradition
conflicts with current guideline-based practice.
2) MCQ
Clinical Scenario:
Six hours after abdominal surgery, a patient reports dizziness
when standing. The blood pressure is 92/58 mm Hg and the
heart rate is 108/min. The incision dressing is dry.
Question Stem:
What is the nurse’s best first action?
, Answer Options:
A. Document the findings as expected after surgery
B. Assist the patient to sit safely, then reassess vital signs and
assess for bleeding
C. Encourage oral fluids and return in 2 hours
D. Administer the prescribed analgesic and reassess later
Correct Answer:
B
Detailed Rationale:
The patient has cues of possible fluid volume deficit or early
postoperative instability. The nurse should first perform
focused reassessment, including hemodynamic status and
possible blood loss, before deciding next steps. This protects
against missing a deteriorating condition.
Incorrect Option Analysis:
A. Incorrect because hypotension and tachycardia are not
expected findings to ignore.
C. Incorrect because delaying assessment risks progression of
instability.
D. Incorrect because pain management is not the priority when
perfusion may be compromised.
Nursing Process Linkage:
Assessment
NCJMM Competencies:
Recognize Cues, Analyze Cues, Take Action
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 new graduate nurse is reviewing a unit practice for central-
line dressing changes. One nurse says, “We have always done it
,this way,” while the current policy references a recent
evidence-based bundle.
Question Stem:
Which action best reflects evidence-based nursing practice?
Answer Options:
A. Continue the long-standing unit routine because it is familiar
to staff
B. Use the practice preferred by the most experienced nurse
C. Compare the current research, facility policy, and patient
factors before choosing the intervention
D. Delay practice changes until an adverse event occurs
Correct Answer:
C
Detailed Rationale:
Evidence-based practice integrates current best research
evidence, clinical expertise, and patient preferences. In med-
surg nursing, safe practice is not based on habit or seniority but
on the best available evidence applied to the individual patient.
Incorrect Option Analysis:
A. Incorrect because tradition alone is not evidence; this may
preserve outdated care.
B. Incorrect because experience is helpful but cannot replace
evidence.
D. Incorrect because waiting for harm is unsafe and unethical.
,Nursing Process Linkage:
Planning
NCJMM Competencies:
Recognize Cues, Analyze Cues, Generate Solutions
Clinical Reasoning Focus:
Decision-Making
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Management of Care
Key Learning Objective:
Select evidence-informed nursing actions when unit tradition
conflicts with current guideline-based practice.
2) MCQ
Clinical Scenario:
Six hours after abdominal surgery, a patient reports dizziness
when standing. The blood pressure is 92/58 mm Hg and the
heart rate is 108/min. The incision dressing is dry.
Question Stem:
What is the nurse’s best first action?
, Answer Options:
A. Document the findings as expected after surgery
B. Assist the patient to sit safely, then reassess vital signs and
assess for bleeding
C. Encourage oral fluids and return in 2 hours
D. Administer the prescribed analgesic and reassess later
Correct Answer:
B
Detailed Rationale:
The patient has cues of possible fluid volume deficit or early
postoperative instability. The nurse should first perform
focused reassessment, including hemodynamic status and
possible blood loss, before deciding next steps. This protects
against missing a deteriorating condition.
Incorrect Option Analysis:
A. Incorrect because hypotension and tachycardia are not
expected findings to ignore.
C. Incorrect because delaying assessment risks progression of
instability.
D. Incorrect because pain management is not the priority when
perfusion may be compromised.
Nursing Process Linkage:
Assessment
NCJMM Competencies:
Recognize Cues, Analyze Cues, Take Action
