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 patient is 2 hours post-op from an open abdominal surgery.
The nurse notes a heart rate of 122/min, blood pressure of
,88/54 mm Hg, pale cool skin, and a saturated abdominal
dressing. The patient says, “I feel dizzy when I turn.”
Question Stem:
What should the nurse do first?
Answer Options:
A. Reassess the patient in 15 minutes because these findings
are common after surgery.
B. Give the prescribed opioid and encourage deep breathing.
C. Activate the rapid response process, stay with the patient,
and prepare to assess for hemorrhage.
D. Document the findings and notify the surgeon at the end of
the shift.
Correct Answer:
C
Detailed Rationale:
The patient shows possible postoperative hemorrhage and
hemodynamic instability. Tachycardia, hypotension, pallor,
dizziness, and a saturated dressing are high-risk cues that
require immediate action. The nurse must recognize cues, act
quickly, and escalate care. Rapid response activation is
appropriate if the patient is unstable. Staying with the patient
supports safety, and preparing to assess for bleeding helps
guide next steps.
Incorrect Option Analysis:
, A: Incorrect. These are not expected postoperative
findings; delaying care increases risk of shock.
B: Incorrect. Pain may be present, but bleeding and
instability take priority over comfort measures.
D: Incorrect. Delayed documentation without intervention
is unsafe and does not address deterioration.
Nursing Process Linkage:
Implementation
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues; Take Action
Clinical Reasoning Focus:
Cue Recognition and Priority Setting
Difficulty Level:
Difficult
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify unstable postoperative cues and prioritize immediate
escalation of care.
2) MCQ
, Clinical Scenario:
A 74-year-old patient with heart failure reports worsening
shortness of breath when lying flat. The nurse notes crackles in
both lungs, 3+ pitting edema, and a 2-kg weight gain in 2 days.
Question Stem:
Which nursing diagnosis is the priority?
Answer Options:
A. Excess fluid volume related to compromised regulatory
mechanisms as evidenced by crackles, edema, and weight gain
B. Disturbed body image related to edema
C. Risk for falls related to age
D. Deficient knowledge related to heart failure diet
Correct Answer:
A
Detailed Rationale:
The data strongly support fluid overload, which is directly
affecting breathing and perfusion. This diagnosis reflects the
highest priority because it addresses a problem that can worsen
rapidly and lead to respiratory compromise.
Incorrect Option Analysis:
B: Incorrect. Body image is relevant but not the immediate
priority.
C: Incorrect. Falls risk is important, but the current cues
point to fluid imbalance.
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 patient is 2 hours post-op from an open abdominal surgery.
The nurse notes a heart rate of 122/min, blood pressure of
,88/54 mm Hg, pale cool skin, and a saturated abdominal
dressing. The patient says, “I feel dizzy when I turn.”
Question Stem:
What should the nurse do first?
Answer Options:
A. Reassess the patient in 15 minutes because these findings
are common after surgery.
B. Give the prescribed opioid and encourage deep breathing.
C. Activate the rapid response process, stay with the patient,
and prepare to assess for hemorrhage.
D. Document the findings and notify the surgeon at the end of
the shift.
Correct Answer:
C
Detailed Rationale:
The patient shows possible postoperative hemorrhage and
hemodynamic instability. Tachycardia, hypotension, pallor,
dizziness, and a saturated dressing are high-risk cues that
require immediate action. The nurse must recognize cues, act
quickly, and escalate care. Rapid response activation is
appropriate if the patient is unstable. Staying with the patient
supports safety, and preparing to assess for bleeding helps
guide next steps.
Incorrect Option Analysis:
, A: Incorrect. These are not expected postoperative
findings; delaying care increases risk of shock.
B: Incorrect. Pain may be present, but bleeding and
instability take priority over comfort measures.
D: Incorrect. Delayed documentation without intervention
is unsafe and does not address deterioration.
Nursing Process Linkage:
Implementation
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues; Take Action
Clinical Reasoning Focus:
Cue Recognition and Priority Setting
Difficulty Level:
Difficult
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify unstable postoperative cues and prioritize immediate
escalation of care.
2) MCQ
, Clinical Scenario:
A 74-year-old patient with heart failure reports worsening
shortness of breath when lying flat. The nurse notes crackles in
both lungs, 3+ pitting edema, and a 2-kg weight gain in 2 days.
Question Stem:
Which nursing diagnosis is the priority?
Answer Options:
A. Excess fluid volume related to compromised regulatory
mechanisms as evidenced by crackles, edema, and weight gain
B. Disturbed body image related to edema
C. Risk for falls related to age
D. Deficient knowledge related to heart failure diet
Correct Answer:
A
Detailed Rationale:
The data strongly support fluid overload, which is directly
affecting breathing and perfusion. This diagnosis reflects the
highest priority because it addresses a problem that can worsen
rapidly and lead to respiratory compromise.
Incorrect Option Analysis:
B: Incorrect. Body image is relevant but not the immediate
priority.
C: Incorrect. Falls risk is important, but the current cues
point to fluid imbalance.
