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 receives report on four adult medical-surgical patients
at the start of shift.
,Question Stem:
Which patient should the nurse assess first?
Answer Options:
A. A postoperative patient who is newly confused, with HR
118/min and BP 98/60 mm Hg
B. A patient with stable heart failure asking for discharge
teaching about fluid restriction
C. A patient who needs help ambulating to the bathroom for
the third time today
D. A patient waiting for a routine prescription refill before
discharge
Correct Answer:
A
Detailed Rationale:
New confusion with tachycardia and hypotension suggests
possible acute deterioration such as hypovolemia, hypoxia,
sepsis, or bleeding. This is the highest-priority cue because the
patient may be unstable. In medical-surgical nursing,
assessment of the most unstable patient comes first.
Incorrect Option Analysis:
B: Important, but stable teaching can wait until urgent
problems are addressed.
C: Routine assistance task; not an immediate threat.
D: Discharge coordination matters, but it is not urgent.
,Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues, Analyze Cues, Prioritize Hypotheses, Take
Action
Clinical Reasoning Focus:
Priority Setting
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation / Management of Care
Key Learning Objective:
Prioritize the most unstable patient using clinical cues and safe
judgment.
2. SATA
Clinical Scenario:
A unit is updating its evidence-based falls-prevention protocol.
Question Stem:
Which actions reflect evidence-based practice and care bundle
implementation? Select all that apply.
, Answer Options:
A. Search current guidelines and systematic reviews before
revising the protocol
B. Combine research evidence with clinical expertise and
patient preferences
C. Apply the bundle consistently for all eligible patients
D. Adopt the protocol because another unit uses it successfully,
without review
E. Measure outcomes after implementation to determine
effectiveness
Correct Answer:
A, B, C, E
Detailed Rationale:
Evidence-based practice integrates best current evidence,
clinical expertise, and patient values. Care bundles are grouped
interventions that are applied consistently to improve
outcomes. Evaluation is essential to confirm the intervention
works in your population.
Incorrect Option Analysis:
D: Popularity is not evidence; this reflects unsafe shortcut
decision-making.
Nursing Process Linkage:
Planning / Implementation / Evaluation
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 receives report on four adult medical-surgical patients
at the start of shift.
,Question Stem:
Which patient should the nurse assess first?
Answer Options:
A. A postoperative patient who is newly confused, with HR
118/min and BP 98/60 mm Hg
B. A patient with stable heart failure asking for discharge
teaching about fluid restriction
C. A patient who needs help ambulating to the bathroom for
the third time today
D. A patient waiting for a routine prescription refill before
discharge
Correct Answer:
A
Detailed Rationale:
New confusion with tachycardia and hypotension suggests
possible acute deterioration such as hypovolemia, hypoxia,
sepsis, or bleeding. This is the highest-priority cue because the
patient may be unstable. In medical-surgical nursing,
assessment of the most unstable patient comes first.
Incorrect Option Analysis:
B: Important, but stable teaching can wait until urgent
problems are addressed.
C: Routine assistance task; not an immediate threat.
D: Discharge coordination matters, but it is not urgent.
,Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues, Analyze Cues, Prioritize Hypotheses, Take
Action
Clinical Reasoning Focus:
Priority Setting
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Analyze
NCLEX Client Needs Category:
Physiological Adaptation / Management of Care
Key Learning Objective:
Prioritize the most unstable patient using clinical cues and safe
judgment.
2. SATA
Clinical Scenario:
A unit is updating its evidence-based falls-prevention protocol.
Question Stem:
Which actions reflect evidence-based practice and care bundle
implementation? Select all that apply.
, Answer Options:
A. Search current guidelines and systematic reviews before
revising the protocol
B. Combine research evidence with clinical expertise and
patient preferences
C. Apply the bundle consistently for all eligible patients
D. Adopt the protocol because another unit uses it successfully,
without review
E. Measure outcomes after implementation to determine
effectiveness
Correct Answer:
A, B, C, E
Detailed Rationale:
Evidence-based practice integrates best current evidence,
clinical expertise, and patient values. Care bundles are grouped
interventions that are applied consistently to improve
outcomes. Evaluation is essential to confirm the intervention
works in your population.
Incorrect Option Analysis:
D: Popularity is not evidence; this reflects unsafe shortcut
decision-making.
Nursing Process Linkage:
Planning / Implementation / Evaluation
