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 Reasoning and the Nursing Process
Clinical Scenario:
A 68-year-old patient is admitted with weakness and dizziness
after several days of poor oral intake. The nurse notes dry
,mucous membranes, heart rate 112/min, blood pressure 96/58
mm Hg, and orthostatic drop in blood pressure.
Question Stem:
Which nursing action best reflects the assessment phase of the
nursing process?
Answer Options:
A. Document the patient as having fluid volume deficit
B. Obtain orthostatic vital signs and ask about recent intake and
output
C. Set a goal that the patient will maintain blood pressure
above 100/60 mm Hg
D. Start the IV fluid infusion as prescribed
Correct Answer:
B. Obtain orthostatic vital signs and ask about recent intake and
output
Detailed Rationale:
Assessment is the systematic collection of subjective and
objective data. Orthostatic vital signs and intake/output data
help the nurse recognize cues suggesting hypovolemia and
guide later diagnosis and intervention. In clinical reasoning,
assessment must come before labeling the problem or acting
on it.
Incorrect Option Analysis:
A. This is a nursing diagnosis or clinical judgment, not
assessment. It reflects interpretation of data already collected.
,C. This is planning, because it identifies a measurable outcome.
D. This is implementation, but it should follow assessment and
analysis.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Analyze Cues
Clinical Reasoning Focus: Cue Recognition, Data Interpretation
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify assessment actions that
support safe clinical reasoning in a changing patient condition.
2) SATA — Evidence-Based Practice Guidelines
Clinical Scenario:
A nurse educator is teaching new staff how to reduce catheter-
associated urinary tract infections (CAUTIs) on a medical-
surgical unit.
Question Stem:
Which actions reflect evidence-based practice? Select all that
apply.
Answer Options:
A. Formulate a clinical question using a PICO format
B. Continue a practice because “it has always been done this
way”
, C. Search current research and clinical guidelines for best
evidence
D. Combine evidence with patient preferences and clinical
expertise
E. Rely only on a single expert’s opinion
Correct Answers:
A, C, D
Detailed Rationale:
Evidence-based practice integrates best current evidence,
clinical expertise, and patient values/preferences. PICO helps
frame searchable questions. Current guidelines and research
support interventions such as bundle-based CAUTI prevention,
while patient needs and context shape how those interventions
are applied.
Incorrect Option Analysis:
B. Tradition alone is not evidence-based and may preserve
unsafe practice.
E. Expert opinion may contribute, but it is not sufficient as the
sole basis for practice. Single-source reasoning increases the
risk of outdated or biased decisions.
Nursing Process Linkage: Planning, Implementation
Clinical Judgment Competencies (NCJMM): Prioritize
Hypotheses, Generate Solutions, Take Action
Clinical Reasoning Focus: Intervention Selection, Care
Coordination
Difficulty Level: Moderate
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 Reasoning and the Nursing Process
Clinical Scenario:
A 68-year-old patient is admitted with weakness and dizziness
after several days of poor oral intake. The nurse notes dry
,mucous membranes, heart rate 112/min, blood pressure 96/58
mm Hg, and orthostatic drop in blood pressure.
Question Stem:
Which nursing action best reflects the assessment phase of the
nursing process?
Answer Options:
A. Document the patient as having fluid volume deficit
B. Obtain orthostatic vital signs and ask about recent intake and
output
C. Set a goal that the patient will maintain blood pressure
above 100/60 mm Hg
D. Start the IV fluid infusion as prescribed
Correct Answer:
B. Obtain orthostatic vital signs and ask about recent intake and
output
Detailed Rationale:
Assessment is the systematic collection of subjective and
objective data. Orthostatic vital signs and intake/output data
help the nurse recognize cues suggesting hypovolemia and
guide later diagnosis and intervention. In clinical reasoning,
assessment must come before labeling the problem or acting
on it.
Incorrect Option Analysis:
A. This is a nursing diagnosis or clinical judgment, not
assessment. It reflects interpretation of data already collected.
,C. This is planning, because it identifies a measurable outcome.
D. This is implementation, but it should follow assessment and
analysis.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Analyze Cues
Clinical Reasoning Focus: Cue Recognition, Data Interpretation
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify assessment actions that
support safe clinical reasoning in a changing patient condition.
2) SATA — Evidence-Based Practice Guidelines
Clinical Scenario:
A nurse educator is teaching new staff how to reduce catheter-
associated urinary tract infections (CAUTIs) on a medical-
surgical unit.
Question Stem:
Which actions reflect evidence-based practice? Select all that
apply.
Answer Options:
A. Formulate a clinical question using a PICO format
B. Continue a practice because “it has always been done this
way”
, C. Search current research and clinical guidelines for best
evidence
D. Combine evidence with patient preferences and clinical
expertise
E. Rely only on a single expert’s opinion
Correct Answers:
A, C, D
Detailed Rationale:
Evidence-based practice integrates best current evidence,
clinical expertise, and patient values/preferences. PICO helps
frame searchable questions. Current guidelines and research
support interventions such as bundle-based CAUTI prevention,
while patient needs and context shape how those interventions
are applied.
Incorrect Option Analysis:
B. Tradition alone is not evidence-based and may preserve
unsafe practice.
E. Expert opinion may contribute, but it is not sufficient as the
sole basis for practice. Single-source reasoning increases the
risk of outdated or biased decisions.
Nursing Process Linkage: Planning, Implementation
Clinical Judgment Competencies (NCJMM): Prioritize
Hypotheses, Generate Solutions, Take Action
Clinical Reasoning Focus: Intervention Selection, Care
Coordination
Difficulty Level: Moderate
