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
Question 1 (MCQ)
Clinical Scenario
A nurse is caring for a 68-year-old patient admitted with
worsening shortness of breath and lower-extremity edema.
During assessment, the nurse notes crackles in both lung bases,
oxygen saturation of 88%, and increasing anxiety.
,Question Stem
Which action best demonstrates the nurse's use of clinical
reasoning?
Options
A. Immediately documenting the findings and continuing the
assessment
B. Recognizing the findings as signs of possible fluid overload
and notifying the provider while initiating prescribed
interventions
C. Waiting for laboratory results before taking action
D. Reassuring the patient that edema is expected with aging
Correct Answer
B
Detailed Rationale
Clinical reasoning involves collecting cues, interpreting data,
identifying priorities, and taking appropriate action. Crackles,
edema, hypoxemia, and anxiety suggest worsening fluid
overload and possible heart failure exacerbation. Prompt
intervention improves patient outcomes and prevents
deterioration.
Incorrect Option Analysis
A: Documentation is important but does not address
immediate patient needs.
,C: Delaying intervention may lead to respiratory compromise.
D: Edema is not a normal consequence of aging and may
indicate pathology.
Nursing Process Linkage
Assessment → Implementation
NCJMM Competencies
Recognize Cues
Analyze Cues
Take Action
Clinical Reasoning Focus
Decision-Making
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Client Needs
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning to recognize and respond to patient
deterioration.
, Question 2 (SATA)
Clinical Scenario
A nurse is explaining QSEN-related competencies that promote
safe healthcare.
Question Stem
Which competencies support safe and effective patient care?
Select All That Apply
A. Patient-centered care
B. Teamwork and collaboration
C. Evidence-based practice
D. Quality improvement
E. Personal opinion-based care
F. Informatics
Correct Answers
A, B, C, D, F
Detailed Rationale
Modern nursing emphasizes patient-centered care, teamwork,
evidence-based practice, quality improvement, and informatics
as essential competencies for healthcare quality and safety.
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
Question 1 (MCQ)
Clinical Scenario
A nurse is caring for a 68-year-old patient admitted with
worsening shortness of breath and lower-extremity edema.
During assessment, the nurse notes crackles in both lung bases,
oxygen saturation of 88%, and increasing anxiety.
,Question Stem
Which action best demonstrates the nurse's use of clinical
reasoning?
Options
A. Immediately documenting the findings and continuing the
assessment
B. Recognizing the findings as signs of possible fluid overload
and notifying the provider while initiating prescribed
interventions
C. Waiting for laboratory results before taking action
D. Reassuring the patient that edema is expected with aging
Correct Answer
B
Detailed Rationale
Clinical reasoning involves collecting cues, interpreting data,
identifying priorities, and taking appropriate action. Crackles,
edema, hypoxemia, and anxiety suggest worsening fluid
overload and possible heart failure exacerbation. Prompt
intervention improves patient outcomes and prevents
deterioration.
Incorrect Option Analysis
A: Documentation is important but does not address
immediate patient needs.
,C: Delaying intervention may lead to respiratory compromise.
D: Edema is not a normal consequence of aging and may
indicate pathology.
Nursing Process Linkage
Assessment → Implementation
NCJMM Competencies
Recognize Cues
Analyze Cues
Take Action
Clinical Reasoning Focus
Decision-Making
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Client Needs
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning to recognize and respond to patient
deterioration.
, Question 2 (SATA)
Clinical Scenario
A nurse is explaining QSEN-related competencies that promote
safe healthcare.
Question Stem
Which competencies support safe and effective patient care?
Select All That Apply
A. Patient-centered care
B. Teamwork and collaboration
C. Evidence-based practice
D. Quality improvement
E. Personal opinion-based care
F. Informatics
Correct Answers
A, B, C, D, F
Detailed Rationale
Modern nursing emphasizes patient-centered care, teamwork,
evidence-based practice, quality improvement, and informatics
as essential competencies for healthcare quality and safety.
Incorrect Option Analysis
