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 nurse on a medical-surgical unit is asked to help update the
unit’s fall-prevention protocol after two recent patient falls.
Question Stem:
Which action best demonstrates evidence-based practice?
Answer Options:
A. Keep the current protocol because it has been used for years
without major complaints.
B. Compare the best current evidence with clinical expertise
and the patient population before revising the protocol.
C. Use the intervention preferred by the charge nurse, then
review outcomes later.
D. Ask staff to follow their usual routines because falls are
expected on a busy unit.
Correct Answer:
B
Detailed Rationale:
Evidence-based practice combines the best available research,
clinical expertise, and patient preferences/values. Updating a
fall-prevention protocol should not rely on tradition, hierarchy,
or habit alone. A safe and effective protocol is built from
current evidence and adapted to the unit’s patient population.
Incorrect Option Analysis:
, A: Tradition is not evidence; this reflects a common
misconception that long use equals effectiveness. It may
preserve unsafe practice.
C: Leadership preference alone is not enough to justify
practice change and may ignore research findings.
D: Routine acceptance of falls reflects poor safety culture
and can increase harm.
Nursing Process Linkage: Planning
Clinical Judgment Competencies (NCJMM): 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: Identify evidence-based practice as the
integration of research evidence, clinical judgment, and
patient-centered care.
2) SATA
Clinical Scenario:
A patient is admitted after laparoscopic surgery. The nurse is
completing the initial assessment.
Question Stem:
Which actions are part of the assessment step of the nursing
process? Select all that apply.
, Answer Options:
A. Ask the patient to rate pain on a 0–10 scale.
B. Write a measurable goal for ambulation.
C. Inspect the surgical dressing for drainage.
D. Administer the ordered analgesic.
E. Review allergies and health history.
F. Evaluate whether the patient walked 50 feet after pain
medication.
Correct Answers:
A, C, E
Detailed Rationale:
Assessment is data collection. Pain rating, wound inspection,
and review of allergies/history are all assessment activities.
These cues help the nurse identify actual and potential
problems before planning care.
Incorrect Option Analysis:
B: This is planning, not assessment; it reflects a common
error of setting goals before data are gathered.
D: This is implementation, not assessment; giving
medication occurs after assessment and decision-making.
F: This is evaluation; it checks response to an intervention.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Analyze Cues
Clinical Reasoning Focus: Cue Recognition
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 nurse on a medical-surgical unit is asked to help update the
unit’s fall-prevention protocol after two recent patient falls.
Question Stem:
Which action best demonstrates evidence-based practice?
Answer Options:
A. Keep the current protocol because it has been used for years
without major complaints.
B. Compare the best current evidence with clinical expertise
and the patient population before revising the protocol.
C. Use the intervention preferred by the charge nurse, then
review outcomes later.
D. Ask staff to follow their usual routines because falls are
expected on a busy unit.
Correct Answer:
B
Detailed Rationale:
Evidence-based practice combines the best available research,
clinical expertise, and patient preferences/values. Updating a
fall-prevention protocol should not rely on tradition, hierarchy,
or habit alone. A safe and effective protocol is built from
current evidence and adapted to the unit’s patient population.
Incorrect Option Analysis:
, A: Tradition is not evidence; this reflects a common
misconception that long use equals effectiveness. It may
preserve unsafe practice.
C: Leadership preference alone is not enough to justify
practice change and may ignore research findings.
D: Routine acceptance of falls reflects poor safety culture
and can increase harm.
Nursing Process Linkage: Planning
Clinical Judgment Competencies (NCJMM): 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: Identify evidence-based practice as the
integration of research evidence, clinical judgment, and
patient-centered care.
2) SATA
Clinical Scenario:
A patient is admitted after laparoscopic surgery. The nurse is
completing the initial assessment.
Question Stem:
Which actions are part of the assessment step of the nursing
process? Select all that apply.
, Answer Options:
A. Ask the patient to rate pain on a 0–10 scale.
B. Write a measurable goal for ambulation.
C. Inspect the surgical dressing for drainage.
D. Administer the ordered analgesic.
E. Review allergies and health history.
F. Evaluate whether the patient walked 50 feet after pain
medication.
Correct Answers:
A, C, E
Detailed Rationale:
Assessment is data collection. Pain rating, wound inspection,
and review of allergies/history are all assessment activities.
These cues help the nurse identify actual and potential
problems before planning care.
Incorrect Option Analysis:
B: This is planning, not assessment; it reflects a common
error of setting goals before data are gathered.
D: This is implementation, not assessment; giving
medication occurs after assessment and decision-making.
F: This is evaluation; it checks response to an intervention.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Analyze Cues
Clinical Reasoning Focus: Cue Recognition
