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 57-year-old patient is admitted to the
medical-surgical unit 2 days after abdominal surgery. During
the first assessment of the shift, the nurse notices restlessness,
shallow breathing, oxygen saturation of 90%, and new crackles
in the lower lung fields.
,Question Stem: Which action best reflects sound clinical
reasoning?
Answer Options:
A. Document anxiety and reassess after lunch.
B. Collect focused respiratory data and compare the findings
with the patient’s baseline before naming the problem.
C. Document acute respiratory failure in the chart.
D. Teach deep-breathing exercises after the next medication
round.
Correct Answer: B
Detailed Rationale: The nurse should first gather and interpret
additional data. Clinical reasoning begins with cue recognition
and focused assessment before assigning a diagnosis or
selecting an intervention. The findings could reflect atelectasis,
pain-related splinting, opioid effect, or early respiratory
compromise.
Incorrect Option Analysis:
A: Incorrect because it minimizes concerning physiologic
cues. Anxiety may coexist, but it does not explain the low
oxygen saturation and crackles. It risks delayed
intervention.
C: Incorrect because it jumps to a medical diagnosis
without sufficient nursing assessment data.
D: Incorrect because teaching is not the priority when
respiratory compromise may be developing.
Nursing Process Linkage: Assessment
, Clinical Judgment Competencies (NCJMM): Recognize
Cues; Analyze Cues
Clinical Reasoning Focus: Cue Recognition
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Distinguish focused assessment
from premature diagnosis in postoperative respiratory
deterioration.
Clinical Reasoning Commentary: An expert nurse does not
anchor on one explanation. The nurse gathers more data,
trends the vitals, assesses breath sounds, pain, sedation,
and airway status, then determines the next safest action.
2) MCQ
Question Number and Type: 2. MCQ
Clinical Scenario: A staff nurse is reviewing a proposed practice
change for reducing catheter-associated urinary tract infections
(CAUTIs) on a medical-surgical unit.
Question Stem: Which statement best describes evidence-
based practice?
Answer Options:
A. Using interventions that have always been done on the unit
B. Combining best research evidence, clinical expertise, and
patient preferences
C. Following provider orders exactly as written
, D. Using the newest equipment available
Correct Answer: B
Detailed Rationale: Evidence-based practice integrates
research findings, the nurse’s clinical judgment, and the
patient’s values and goals. It is not simply tradition, authority,
or new technology.
Incorrect Option Analysis:
A: Incorrect because tradition alone is not evidence.
C: Incorrect because provider orders are part of care, but
they are not the full definition of EBP.
D: Incorrect because new equipment is not automatically
evidence-based.
Nursing Process Linkage: Planning
Clinical Judgment Competencies (NCJMM): Prioritize
Hypotheses; Generate Solutions
Clinical Reasoning Focus: Decision-Making
Difficulty Level: Easy
Bloom’s Cognitive Level: Understand
NCLEX Client Needs Category: Management of Care
Key Learning Objective: Define evidence-based practice in
a way that supports safe adult health nursing care.
Clinical Reasoning Commentary: Expert practice is not
based on habit. The nurse weighs research, bedside
expertise, and what matters to the patient before
choosing a plan.
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 57-year-old patient is admitted to the
medical-surgical unit 2 days after abdominal surgery. During
the first assessment of the shift, the nurse notices restlessness,
shallow breathing, oxygen saturation of 90%, and new crackles
in the lower lung fields.
,Question Stem: Which action best reflects sound clinical
reasoning?
Answer Options:
A. Document anxiety and reassess after lunch.
B. Collect focused respiratory data and compare the findings
with the patient’s baseline before naming the problem.
C. Document acute respiratory failure in the chart.
D. Teach deep-breathing exercises after the next medication
round.
Correct Answer: B
Detailed Rationale: The nurse should first gather and interpret
additional data. Clinical reasoning begins with cue recognition
and focused assessment before assigning a diagnosis or
selecting an intervention. The findings could reflect atelectasis,
pain-related splinting, opioid effect, or early respiratory
compromise.
Incorrect Option Analysis:
A: Incorrect because it minimizes concerning physiologic
cues. Anxiety may coexist, but it does not explain the low
oxygen saturation and crackles. It risks delayed
intervention.
C: Incorrect because it jumps to a medical diagnosis
without sufficient nursing assessment data.
D: Incorrect because teaching is not the priority when
respiratory compromise may be developing.
Nursing Process Linkage: Assessment
, Clinical Judgment Competencies (NCJMM): Recognize
Cues; Analyze Cues
Clinical Reasoning Focus: Cue Recognition
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Distinguish focused assessment
from premature diagnosis in postoperative respiratory
deterioration.
Clinical Reasoning Commentary: An expert nurse does not
anchor on one explanation. The nurse gathers more data,
trends the vitals, assesses breath sounds, pain, sedation,
and airway status, then determines the next safest action.
2) MCQ
Question Number and Type: 2. MCQ
Clinical Scenario: A staff nurse is reviewing a proposed practice
change for reducing catheter-associated urinary tract infections
(CAUTIs) on a medical-surgical unit.
Question Stem: Which statement best describes evidence-
based practice?
Answer Options:
A. Using interventions that have always been done on the unit
B. Combining best research evidence, clinical expertise, and
patient preferences
C. Following provider orders exactly as written
, D. Using the newest equipment available
Correct Answer: B
Detailed Rationale: Evidence-based practice integrates
research findings, the nurse’s clinical judgment, and the
patient’s values and goals. It is not simply tradition, authority,
or new technology.
Incorrect Option Analysis:
A: Incorrect because tradition alone is not evidence.
C: Incorrect because provider orders are part of care, but
they are not the full definition of EBP.
D: Incorrect because new equipment is not automatically
evidence-based.
Nursing Process Linkage: Planning
Clinical Judgment Competencies (NCJMM): Prioritize
Hypotheses; Generate Solutions
Clinical Reasoning Focus: Decision-Making
Difficulty Level: Easy
Bloom’s Cognitive Level: Understand
NCLEX Client Needs Category: Management of Care
Key Learning Objective: Define evidence-based practice in
a way that supports safe adult health nursing care.
Clinical Reasoning Commentary: Expert practice is not
based on habit. The nurse weighs research, bedside
expertise, and what matters to the patient before
choosing a plan.
