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 reasoning and first priority
,Clinical scenario: A postoperative client is 2 hours after
abdominal surgery. The nurse notes that the incision dressing is
now saturated with bright red drainage, the client’s heart rate
is 122/min, blood pressure is 90/58 mm Hg, and the client
reports feeling “lightheaded.”
Question stem: What is the nurse’s priority action?
Answer options:
A. Assess the surgical site and quantify the amount of drainage
B. Administer the prescribed opioid for pain relief
C. Document the findings and reassess in 30 minutes
D. Encourage the client to ambulate to prevent venous stasis
Correct answer: A
Detailed rationale: Bright red drainage with tachycardia,
hypotension, and lightheadedness suggests active bleeding and
possible hypovolemia. The nurse should first assess the source
and extent of bleeding to guide rapid intervention and
escalation. This is an assessment-based action that supports
early recognition of deterioration and patient safety.
Incorrect option analysis:
B: Pain management is important, but it does not address
a potentially life-threatening hemorrhage. This reflects the
misconception that comfort comes before stabilization.
C: Delaying action risks worsening shock and organ
hypoperfusion.
, D: Ambulation is unsafe in a potentially unstable client and
could worsen dizziness or falls.
Nursing process linkage: Assessment
NCJMM competencies: Recognize Cues; Analyze Cues; Take
Action
Clinical reasoning focus: Priority setting and cue recognition
Difficulty: Moderate
Bloom’s cognitive level: Analyze
NCLEX client needs category: Physiological Adaptation; Safety
and Infection Control
Key learning objective: Identify signs of postoperative
deterioration and prioritize immediate assessment for bleeding.
2. MCQ — Nursing diagnosis vs. medical diagnosis
Clinical scenario: A client on postoperative day 1 has a
temperature of 38.3°C (100.9°F), coarse crackles, a productive
cough, and shallow breathing. The provider has not yet
diagnosed the cause.
Question stem: Which statement is the best example of a
nursing diagnosis?
Answer options:
A. Ineffective airway clearance related to retained secretions
B. Pneumonia
C. Chest physiotherapy
D. Fever caused by infection
, Correct answer: A
Detailed rationale: A nursing diagnosis describes the client’s
response to a health problem. “Ineffective airway clearance
related to retained secretions” identifies a treatable nursing
response based on assessment cues. It is distinct from a
medical diagnosis.
Incorrect option analysis:
B: Pneumonia is a medical diagnosis, not a nursing
diagnosis.
C: Chest physiotherapy is an intervention, not a diagnosis.
D: This is a statement of presumed cause, not a
standardized nursing diagnosis.
Nursing process linkage: Diagnosis
NCJMM competencies: Recognize Cues; Analyze Cues;
Prioritize Hypotheses
Clinical reasoning focus: Data interpretation and hypothesis
generation
Difficulty: Easy
Bloom’s cognitive level: Understand
NCLEX client needs category: Physiological Adaptation
Key learning objective: Distinguish nursing diagnoses from
medical diagnoses and interventions.
3. MCQ — Evidence-based practice and care bundles
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 reasoning and first priority
,Clinical scenario: A postoperative client is 2 hours after
abdominal surgery. The nurse notes that the incision dressing is
now saturated with bright red drainage, the client’s heart rate
is 122/min, blood pressure is 90/58 mm Hg, and the client
reports feeling “lightheaded.”
Question stem: What is the nurse’s priority action?
Answer options:
A. Assess the surgical site and quantify the amount of drainage
B. Administer the prescribed opioid for pain relief
C. Document the findings and reassess in 30 minutes
D. Encourage the client to ambulate to prevent venous stasis
Correct answer: A
Detailed rationale: Bright red drainage with tachycardia,
hypotension, and lightheadedness suggests active bleeding and
possible hypovolemia. The nurse should first assess the source
and extent of bleeding to guide rapid intervention and
escalation. This is an assessment-based action that supports
early recognition of deterioration and patient safety.
Incorrect option analysis:
B: Pain management is important, but it does not address
a potentially life-threatening hemorrhage. This reflects the
misconception that comfort comes before stabilization.
C: Delaying action risks worsening shock and organ
hypoperfusion.
, D: Ambulation is unsafe in a potentially unstable client and
could worsen dizziness or falls.
Nursing process linkage: Assessment
NCJMM competencies: Recognize Cues; Analyze Cues; Take
Action
Clinical reasoning focus: Priority setting and cue recognition
Difficulty: Moderate
Bloom’s cognitive level: Analyze
NCLEX client needs category: Physiological Adaptation; Safety
and Infection Control
Key learning objective: Identify signs of postoperative
deterioration and prioritize immediate assessment for bleeding.
2. MCQ — Nursing diagnosis vs. medical diagnosis
Clinical scenario: A client on postoperative day 1 has a
temperature of 38.3°C (100.9°F), coarse crackles, a productive
cough, and shallow breathing. The provider has not yet
diagnosed the cause.
Question stem: Which statement is the best example of a
nursing diagnosis?
Answer options:
A. Ineffective airway clearance related to retained secretions
B. Pneumonia
C. Chest physiotherapy
D. Fever caused by infection
, Correct answer: A
Detailed rationale: A nursing diagnosis describes the client’s
response to a health problem. “Ineffective airway clearance
related to retained secretions” identifies a treatable nursing
response based on assessment cues. It is distinct from a
medical diagnosis.
Incorrect option analysis:
B: Pneumonia is a medical diagnosis, not a nursing
diagnosis.
C: Chest physiotherapy is an intervention, not a diagnosis.
D: This is a statement of presumed cause, not a
standardized nursing diagnosis.
Nursing process linkage: Diagnosis
NCJMM competencies: Recognize Cues; Analyze Cues;
Prioritize Hypotheses
Clinical reasoning focus: Data interpretation and hypothesis
generation
Difficulty: Easy
Bloom’s cognitive level: Understand
NCLEX client needs category: Physiological Adaptation
Key learning objective: Distinguish nursing diagnoses from
medical diagnoses and interventions.
3. MCQ — Evidence-based practice and care bundles
