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 reviewing a patient’s
admission data and notices that the patient’s home
antihypertensive medication was omitted from the medication
reconciliation list.
Question Stem
Which action best reflects clinical reasoning in this situation?
Answer Options
A. Wait until the next shift to mention the omission
B. Document the omission in the chart and continue with other
tasks
C. Notify the provider or pharmacist and verify the medication
list promptly
D. Tell the patient to bring the medication from home
Correct Answer
C
Detailed Rationale
Medication reconciliation is a patient-safety process that
prevents omissions, duplications, and drug interactions. The
nurse uses clinical reasoning by recognizing a cue with potential
harm, analyzing its significance, and taking immediate action to
reduce risk. Verifying the medication list promptly supports
continuity of care and evidence-informed safety practice.
Incorrect Option Analysis
, A: Delaying action increases risk for uncontrolled blood
pressure or withdrawal effects. This reflects poor
prioritization.
B: Documentation alone does not correct the problem. It
may reflect passive reporting rather than safety action.
D: The patient should not be relied on to solve a
reconciliation error; the nurse must verify the medication
independently.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues; Analyze Cues; Take Action
Clinical Reasoning Focus
Cue Recognition; Decision-Making
Difficulty Level
Moderate
Bloom’s Cognitive Level
Apply
NCLEX Client Needs Category
Safety and Infection Control; Management of Care
Key Learning Objective
Identify patient-safety cues and respond using prompt clinical
judgment during admission assessment.
, 2) SATA
Clinical Scenario
A nurse manager is teaching staff about core competencies for
safe and effective healthcare.
Question Stem
Which actions reflect core competencies for safe and effective
healthcare? Select all that apply.
Answer Options
A. Using standardized handoff communication
B. Reporting a near miss through the facility safety process
C. Asking the unlicensed assistive personnel to interpret a
wound assessment
D. Confirming patient identity using two identifiers before
medication administration
E. Sharing a patient update with a family member who is not
listed in the chart
F. Using evidence-based guidelines when planning care
Correct Answers
A, B, D, F
Detailed Rationale
Safe and effective care depends on communication, safety
reporting, identity verification, and evidence-based decision-
making. Standardized handoff communication reduces errors.
Near-miss reporting supports quality improvement. Two-
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 reviewing a patient’s
admission data and notices that the patient’s home
antihypertensive medication was omitted from the medication
reconciliation list.
Question Stem
Which action best reflects clinical reasoning in this situation?
Answer Options
A. Wait until the next shift to mention the omission
B. Document the omission in the chart and continue with other
tasks
C. Notify the provider or pharmacist and verify the medication
list promptly
D. Tell the patient to bring the medication from home
Correct Answer
C
Detailed Rationale
Medication reconciliation is a patient-safety process that
prevents omissions, duplications, and drug interactions. The
nurse uses clinical reasoning by recognizing a cue with potential
harm, analyzing its significance, and taking immediate action to
reduce risk. Verifying the medication list promptly supports
continuity of care and evidence-informed safety practice.
Incorrect Option Analysis
, A: Delaying action increases risk for uncontrolled blood
pressure or withdrawal effects. This reflects poor
prioritization.
B: Documentation alone does not correct the problem. It
may reflect passive reporting rather than safety action.
D: The patient should not be relied on to solve a
reconciliation error; the nurse must verify the medication
independently.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues; Analyze Cues; Take Action
Clinical Reasoning Focus
Cue Recognition; Decision-Making
Difficulty Level
Moderate
Bloom’s Cognitive Level
Apply
NCLEX Client Needs Category
Safety and Infection Control; Management of Care
Key Learning Objective
Identify patient-safety cues and respond using prompt clinical
judgment during admission assessment.
, 2) SATA
Clinical Scenario
A nurse manager is teaching staff about core competencies for
safe and effective healthcare.
Question Stem
Which actions reflect core competencies for safe and effective
healthcare? Select all that apply.
Answer Options
A. Using standardized handoff communication
B. Reporting a near miss through the facility safety process
C. Asking the unlicensed assistive personnel to interpret a
wound assessment
D. Confirming patient identity using two identifiers before
medication administration
E. Sharing a patient update with a family member who is not
listed in the chart
F. Using evidence-based guidelines when planning care
Correct Answers
A, B, D, F
Detailed Rationale
Safe and effective care depends on communication, safety
reporting, identity verification, and evidence-based decision-
making. Standardized handoff communication reduces errors.
Near-miss reporting supports quality improvement. Two-
