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 medical-surgical nurse begins a shift caring for four patients.
During handoff, the nurse receives the following information:
Patient A: Postoperative day 1 after colectomy; pain rated
6/10.
Patient B: Newly admitted with shortness of breath and
oxygen saturation of 88% on room air.
Patient C: Awaiting discharge instructions after treatment
for cellulitis.
Patient D: Stable patient requesting assistance with
bathing.
Question Stem
Which patient should the nurse assess first using clinical
reasoning and prioritization principles?
Answer Options
A. Patient A
B. Patient B
C. Patient C
D. Patient D
Correct Answer
B. Patient B
Detailed Rationale
,Clinical reasoning requires recognizing cues that indicate actual
or potential threats to life. An oxygen saturation of 88%
indicates impaired oxygenation, which poses an immediate
physiologic risk. Airway, breathing, and circulation (ABC)
principles guide prioritization. Prompt assessment may identify
respiratory failure, pneumonia, pulmonary edema, or another
serious condition.
Incorrect Option Analysis
A. Patient A
Incorrect because pain management is important but not
the highest priority.
Misconception: Assuming pain always takes precedence.
Safety implication: Delaying assessment of hypoxemia may
lead to deterioration.
C. Patient C
Incorrect because discharge teaching can occur after
urgent needs are addressed.
Misconception: Prioritizing scheduled tasks over unstable
conditions.
Safety implication: Minimal immediate risk.
D. Patient D
Incorrect because assistance with bathing is a comfort
need.
, Misconception: Addressing requests in order received.
Safety implication: Does not address life-threatening
concerns.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
Analyze Cues
Prioritize Hypotheses
Clinical Reasoning Focus
Priority Setting
Difficulty Level
Moderate
Bloom's Cognitive Level
Analyze
NCLEX Client Needs Category
Physiological Adaptation
Key Learning Objective
Prioritize patient care using clinical reasoning and ABC
principles.
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 medical-surgical nurse begins a shift caring for four patients.
During handoff, the nurse receives the following information:
Patient A: Postoperative day 1 after colectomy; pain rated
6/10.
Patient B: Newly admitted with shortness of breath and
oxygen saturation of 88% on room air.
Patient C: Awaiting discharge instructions after treatment
for cellulitis.
Patient D: Stable patient requesting assistance with
bathing.
Question Stem
Which patient should the nurse assess first using clinical
reasoning and prioritization principles?
Answer Options
A. Patient A
B. Patient B
C. Patient C
D. Patient D
Correct Answer
B. Patient B
Detailed Rationale
,Clinical reasoning requires recognizing cues that indicate actual
or potential threats to life. An oxygen saturation of 88%
indicates impaired oxygenation, which poses an immediate
physiologic risk. Airway, breathing, and circulation (ABC)
principles guide prioritization. Prompt assessment may identify
respiratory failure, pneumonia, pulmonary edema, or another
serious condition.
Incorrect Option Analysis
A. Patient A
Incorrect because pain management is important but not
the highest priority.
Misconception: Assuming pain always takes precedence.
Safety implication: Delaying assessment of hypoxemia may
lead to deterioration.
C. Patient C
Incorrect because discharge teaching can occur after
urgent needs are addressed.
Misconception: Prioritizing scheduled tasks over unstable
conditions.
Safety implication: Minimal immediate risk.
D. Patient D
Incorrect because assistance with bathing is a comfort
need.
, Misconception: Addressing requests in order received.
Safety implication: Does not address life-threatening
concerns.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
Analyze Cues
Prioritize Hypotheses
Clinical Reasoning Focus
Priority Setting
Difficulty Level
Moderate
Bloom's Cognitive Level
Analyze
NCLEX Client Needs Category
Physiological Adaptation
Key Learning Objective
Prioritize patient care using clinical reasoning and ABC
principles.
