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 is admitting a client with worsening shortness of breath
and fatigue. The client says, “I have not been able to sleep flat
for three nights.” The nurse notices the client is speaking in
short phrases.
Question Stem:
Which nursing action best reflects the assessment phase of
clinical reasoning?
Answer Options:
A. Document the client’s statement as anxiety-related
B. Measure vital signs and oxygen saturation immediately
C. Administer oxygen at 2 L/min via nasal cannula
D. Teach the client to sleep with extra pillows
Correct Answer:
B. Measure vital signs and oxygen saturation immediately
Detailed Rationale:
Assessment requires the nurse to gather data before selecting
interventions. The client’s orthopnea, fatigue, and dyspnea may
indicate cardiopulmonary compromise, so obtaining objective
data such as vital signs and oxygen saturation is the safest first
step. This supports clinical reasoning by confirming cues before
action.
Incorrect Option Analysis:
A: Premature interpretation. Anxiety may be present, but
the nurse must first assess physiologic causes.
, Misconception: assuming symptoms are emotional. Safety
risk: delayed recognition of deterioration.
C: Intervention before full assessment. Oxygen may be
appropriate, but the nurse should first determine severity
and need. Misconception: treating before gathering cues.
D: Teaching is important, but not the priority during acute
symptoms. Misconception: education before stabilization.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues, Analyze Cues
Clinical Reasoning Focus:
Cue Recognition
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify the nurse’s first action when cues suggest possible
acute respiratory compromise.
, 2) SATA
Clinical Scenario:
A new graduate nurse is reviewing professional conduct
expectations during orientation.
Question Stem:
Which actions demonstrate professional boundaries and
ethical practice? Select all that apply.
Answer Options:
A. Declining a patient’s request to connect on social media
B. Discussing a patient’s diagnosis with a friend who works on
another unit
C. Keeping the nurse-patient relationship focused on the
patient’s health goals
D. Accepting a patient’s expensive gift after discharge
E. Asking the charge nurse for guidance when a situation feels
ethically unclear
Correct Answer:
A, C, E
Detailed Rationale:
Professional boundaries protect the therapeutic relationship
and patient trust. Declining social media contact maintains role
clarity. Focusing interactions on health goals supports patient-
centered care. Seeking guidance when uncertain reflects ethical
practice and protects both patient and nurse.
Incorrect Option Analysis:
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 is admitting a client with worsening shortness of breath
and fatigue. The client says, “I have not been able to sleep flat
for three nights.” The nurse notices the client is speaking in
short phrases.
Question Stem:
Which nursing action best reflects the assessment phase of
clinical reasoning?
Answer Options:
A. Document the client’s statement as anxiety-related
B. Measure vital signs and oxygen saturation immediately
C. Administer oxygen at 2 L/min via nasal cannula
D. Teach the client to sleep with extra pillows
Correct Answer:
B. Measure vital signs and oxygen saturation immediately
Detailed Rationale:
Assessment requires the nurse to gather data before selecting
interventions. The client’s orthopnea, fatigue, and dyspnea may
indicate cardiopulmonary compromise, so obtaining objective
data such as vital signs and oxygen saturation is the safest first
step. This supports clinical reasoning by confirming cues before
action.
Incorrect Option Analysis:
A: Premature interpretation. Anxiety may be present, but
the nurse must first assess physiologic causes.
, Misconception: assuming symptoms are emotional. Safety
risk: delayed recognition of deterioration.
C: Intervention before full assessment. Oxygen may be
appropriate, but the nurse should first determine severity
and need. Misconception: treating before gathering cues.
D: Teaching is important, but not the priority during acute
symptoms. Misconception: education before stabilization.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues, Analyze Cues
Clinical Reasoning Focus:
Cue Recognition
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify the nurse’s first action when cues suggest possible
acute respiratory compromise.
, 2) SATA
Clinical Scenario:
A new graduate nurse is reviewing professional conduct
expectations during orientation.
Question Stem:
Which actions demonstrate professional boundaries and
ethical practice? Select all that apply.
Answer Options:
A. Declining a patient’s request to connect on social media
B. Discussing a patient’s diagnosis with a friend who works on
another unit
C. Keeping the nurse-patient relationship focused on the
patient’s health goals
D. Accepting a patient’s expensive gift after discharge
E. Asking the charge nurse for guidance when a situation feels
ethically unclear
Correct Answer:
A, C, E
Detailed Rationale:
Professional boundaries protect the therapeutic relationship
and patient trust. Declining social media contact maintains role
clarity. Focusing interactions on health goals supports patient-
centered care. Seeking guidance when uncertain reflects ethical
practice and protects both patient and nurse.
Incorrect Option Analysis:
