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
Question Number and Type: 1. MCQ
,Clinical Scenario:
A newly hired medical-surgical nurse is caring for a patient
whose blood pressure drops suddenly after receiving an
antihypertensive medication. The nurse recognizes that rapid
action is needed to prevent harm.
Question Stem:
Which action best reflects the nurse’s role in promoting safe
and effective care?
Answer Options:
A. Document the low blood pressure at the end of the shift
B. Reassess the patient, review the medication timing, and
notify the provider promptly
C. Wait 30 minutes to see whether the blood pressure returns
to baseline
D. Ask another nurse to decide whether the medication caused
the change
Correct Answer:
B. Reassess the patient, review the medication timing, and
notify the provider promptly
Detailed Rationale:
The nurse must use clinical reasoning to recognize a potentially
adverse medication effect and act immediately. Reassessment
confirms the severity of the change and helps determine
whether the patient is symptomatic. Reviewing the medication
timing supports analysis of likely cause. Prompt notification
supports timely intervention and patient safety. This reflects
,the nurse’s responsibility for surveillance, recognition of
deterioration, and escalation of care.
Incorrect Option Analysis:
A. Delaying documentation postpones clinical response and
increases the risk of harm.
C. Waiting may allow hypotension to worsen, especially if the
patient is symptomatic or has impaired perfusion.
D. The nurse remains accountable for initial assessment and
action; delegation of judgment is unsafe.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues; Take Action
Clinical Reasoning Focus:
Cue Recognition; Decision-Making
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify the nurse’s responsibility to assess, analyze, and
, respond to unexpected physiologic changes to protect patient
safety.
2) SATA
Question Number and Type: 2. SATA
Clinical Scenario:
A nurse is reviewing the steps of the nursing process with a
group of students during orientation.
Question Stem:
Which actions are part of the assessment phase of the nursing
process? Select all that apply.
Answer Options:
A. Asking the patient about pain characteristics
B. Formulating a nursing diagnosis of acute pain
C. Measuring oxygen saturation
D. Setting a goal that the patient will ambulate twice daily
E. Reviewing laboratory results
Correct Answer:
A, C, E
Detailed Rationale:
Assessment includes data collection from subjective and
objective sources. Asking about pain characteristics gathers
subjective data. Measuring oxygen saturation and reviewing
laboratory results are objective assessment activities. These
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
1) MCQ
Question Number and Type: 1. MCQ
,Clinical Scenario:
A newly hired medical-surgical nurse is caring for a patient
whose blood pressure drops suddenly after receiving an
antihypertensive medication. The nurse recognizes that rapid
action is needed to prevent harm.
Question Stem:
Which action best reflects the nurse’s role in promoting safe
and effective care?
Answer Options:
A. Document the low blood pressure at the end of the shift
B. Reassess the patient, review the medication timing, and
notify the provider promptly
C. Wait 30 minutes to see whether the blood pressure returns
to baseline
D. Ask another nurse to decide whether the medication caused
the change
Correct Answer:
B. Reassess the patient, review the medication timing, and
notify the provider promptly
Detailed Rationale:
The nurse must use clinical reasoning to recognize a potentially
adverse medication effect and act immediately. Reassessment
confirms the severity of the change and helps determine
whether the patient is symptomatic. Reviewing the medication
timing supports analysis of likely cause. Prompt notification
supports timely intervention and patient safety. This reflects
,the nurse’s responsibility for surveillance, recognition of
deterioration, and escalation of care.
Incorrect Option Analysis:
A. Delaying documentation postpones clinical response and
increases the risk of harm.
C. Waiting may allow hypotension to worsen, especially if the
patient is symptomatic or has impaired perfusion.
D. The nurse remains accountable for initial assessment and
action; delegation of judgment is unsafe.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues; Take Action
Clinical Reasoning Focus:
Cue Recognition; Decision-Making
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify the nurse’s responsibility to assess, analyze, and
, respond to unexpected physiologic changes to protect patient
safety.
2) SATA
Question Number and Type: 2. SATA
Clinical Scenario:
A nurse is reviewing the steps of the nursing process with a
group of students during orientation.
Question Stem:
Which actions are part of the assessment phase of the nursing
process? Select all that apply.
Answer Options:
A. Asking the patient about pain characteristics
B. Formulating a nursing diagnosis of acute pain
C. Measuring oxygen saturation
D. Setting a goal that the patient will ambulate twice daily
E. Reviewing laboratory results
Correct Answer:
A, C, E
Detailed Rationale:
Assessment includes data collection from subjective and
objective sources. Asking about pain characteristics gathers
subjective data. Measuring oxygen saturation and reviewing
laboratory results are objective assessment activities. These
