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 caring for a postoperative patient
whose blood pressure drops from 128/76 to 92/58 mm Hg,
heart rate increases from 82 to 114/min, and the patient
reports feeling “light-headed.”
Question Stem:
Which action best reflects the first step in clinical reasoning?
A. Administer a prescribed analgesic
B. Recognize and analyze the new cues
C. Document the findings in the chart
D. Reassure the patient that these changes are expected
Correct Answer:
B. Recognize and analyze the new cues
Detailed Rationale:
Clinical reasoning begins with noticing and interpreting cues.
The drop in blood pressure, tachycardia, and light-headedness
may indicate bleeding, hypovolemia, or another acute
complication requiring prompt assessment. Safe nursing
practice requires the nurse to identify the significance of the
change before choosing an intervention. This aligns with the
NCJMM steps of recognizing cues and analyzing cues.
Incorrect Option Analysis:
A: Pain control may be appropriate later, but giving
analgesia first could delay recognition of deterioration.
, C: Documentation is necessary, but it is not the first clinical
reasoning step when a patient may be unstable.
D: These changes are not routine postoperative findings
and should not be minimized.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues
Clinical Reasoning Focus:
Cue Recognition
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify early warning cues of patient deterioration and initiate
the reasoning process appropriately.
2) MCQ
Clinical Scenario:
A nurse is revising a care plan for a patient with heart failure,
, diabetes, and limited health literacy. The patient says, “I want
to understand my medicines in a way that makes sense to me.”
Question Stem:
Which nursing action best demonstrates patient-centered care?
A. Provide the standard discharge packet only
B. Focus teaching on the nurse’s preferred learning method
C. Include the patient’s goals, preferences, and understanding
in teaching
D. Ask the family to make all decisions without patient input
Correct Answer:
C. Include the patient’s goals, preferences, and understanding
in teaching
Detailed Rationale:
Patient-centered care respects the patient’s values, literacy
level, culture, and preferences. Education should be tailored to
the patient’s ability to understand and apply the information.
This improves adherence, self-management, and safety. It also
supports shared decision-making and continuity of care.
Incorrect Option Analysis:
A: A standard packet alone may not meet the patient’s
learning needs.
B: Teaching should match the patient’s needs, not the
nurse’s preference.
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 caring for a postoperative patient
whose blood pressure drops from 128/76 to 92/58 mm Hg,
heart rate increases from 82 to 114/min, and the patient
reports feeling “light-headed.”
Question Stem:
Which action best reflects the first step in clinical reasoning?
A. Administer a prescribed analgesic
B. Recognize and analyze the new cues
C. Document the findings in the chart
D. Reassure the patient that these changes are expected
Correct Answer:
B. Recognize and analyze the new cues
Detailed Rationale:
Clinical reasoning begins with noticing and interpreting cues.
The drop in blood pressure, tachycardia, and light-headedness
may indicate bleeding, hypovolemia, or another acute
complication requiring prompt assessment. Safe nursing
practice requires the nurse to identify the significance of the
change before choosing an intervention. This aligns with the
NCJMM steps of recognizing cues and analyzing cues.
Incorrect Option Analysis:
A: Pain control may be appropriate later, but giving
analgesia first could delay recognition of deterioration.
, C: Documentation is necessary, but it is not the first clinical
reasoning step when a patient may be unstable.
D: These changes are not routine postoperative findings
and should not be minimized.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues
Clinical Reasoning Focus:
Cue Recognition
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify early warning cues of patient deterioration and initiate
the reasoning process appropriately.
2) MCQ
Clinical Scenario:
A nurse is revising a care plan for a patient with heart failure,
, diabetes, and limited health literacy. The patient says, “I want
to understand my medicines in a way that makes sense to me.”
Question Stem:
Which nursing action best demonstrates patient-centered care?
A. Provide the standard discharge packet only
B. Focus teaching on the nurse’s preferred learning method
C. Include the patient’s goals, preferences, and understanding
in teaching
D. Ask the family to make all decisions without patient input
Correct Answer:
C. Include the patient’s goals, preferences, and understanding
in teaching
Detailed Rationale:
Patient-centered care respects the patient’s values, literacy
level, culture, and preferences. Education should be tailored to
the patient’s ability to understand and apply the information.
This improves adherence, self-management, and safety. It also
supports shared decision-making and continuity of care.
Incorrect Option Analysis:
A: A standard packet alone may not meet the patient’s
learning needs.
B: Teaching should match the patient’s needs, not the
nurse’s preference.
