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 on a medical-surgical unit receives shift report on four
patients. During morning rounds, the nurse notes that one
patient with pneumonia has an oxygen saturation of 88% on
,room air, another patient requests discharge instructions, a
third requests pain medication for chronic arthritis pain rated
4/10, and a fourth asks for assistance ordering lunch.
Question Stem
Which action best demonstrates the nurse's use of clinical
reasoning and prioritization?
Answer Options
A. Provide discharge teaching first because it takes the most
time
B. Administer pain medication before completing assessments
C. Assess the patient with oxygen saturation of 88% first
D. Assist the patient with meal ordering first
Correct Answer
C. Assess the patient with oxygen saturation of 88% first
Detailed Rationale
Clinical reasoning requires recognizing cues that indicate
potential physiologic instability. An oxygen saturation of 88%
suggests impaired oxygenation and possible deterioration.
Airway, breathing, and circulation (ABC) principles support
immediate assessment and intervention. Patient safety takes
precedence over routine care activities.
Incorrect Option Analysis
,A: Discharge teaching is important but does not address an
immediate physiologic concern.
B: Pain management is necessary; however, chronic pain rated
4/10 is not the highest priority.
D: Meal ordering promotes comfort but can safely be delayed.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
Prioritize Hypotheses
Take Action
Clinical Reasoning Focus
Priority Setting
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Category
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning to prioritize patient care needs.
, Question 2 (SATA)
Clinical Scenario
A nurse is discussing core competencies for safe and effective
healthcare with a newly hired graduate nurse.
Question Stem
Which competencies are considered essential for safe and
effective healthcare? Select all that apply.
Answer Options
A. Patient-centered care
B. Evidence-based practice
C. Quality improvement
D. Informatics
E. Independent physician decision-making
F. Teamwork and collaboration
Correct Answers
A, B, C, D, F
Detailed Rationale
Modern healthcare competencies emphasize patient-centered
care, teamwork, evidence-based practice, quality improvement,
and informatics. These competencies improve safety and
patient outcomes.
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 on a medical-surgical unit receives shift report on four
patients. During morning rounds, the nurse notes that one
patient with pneumonia has an oxygen saturation of 88% on
,room air, another patient requests discharge instructions, a
third requests pain medication for chronic arthritis pain rated
4/10, and a fourth asks for assistance ordering lunch.
Question Stem
Which action best demonstrates the nurse's use of clinical
reasoning and prioritization?
Answer Options
A. Provide discharge teaching first because it takes the most
time
B. Administer pain medication before completing assessments
C. Assess the patient with oxygen saturation of 88% first
D. Assist the patient with meal ordering first
Correct Answer
C. Assess the patient with oxygen saturation of 88% first
Detailed Rationale
Clinical reasoning requires recognizing cues that indicate
potential physiologic instability. An oxygen saturation of 88%
suggests impaired oxygenation and possible deterioration.
Airway, breathing, and circulation (ABC) principles support
immediate assessment and intervention. Patient safety takes
precedence over routine care activities.
Incorrect Option Analysis
,A: Discharge teaching is important but does not address an
immediate physiologic concern.
B: Pain management is necessary; however, chronic pain rated
4/10 is not the highest priority.
D: Meal ordering promotes comfort but can safely be delayed.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
Prioritize Hypotheses
Take Action
Clinical Reasoning Focus
Priority Setting
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Category
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning to prioritize patient care needs.
, Question 2 (SATA)
Clinical Scenario
A nurse is discussing core competencies for safe and effective
healthcare with a newly hired graduate nurse.
Question Stem
Which competencies are considered essential for safe and
effective healthcare? Select all that apply.
Answer Options
A. Patient-centered care
B. Evidence-based practice
C. Quality improvement
D. Informatics
E. Independent physician decision-making
F. Teamwork and collaboration
Correct Answers
A, B, C, D, F
Detailed Rationale
Modern healthcare competencies emphasize patient-centered
care, teamwork, evidence-based practice, quality improvement,
and informatics. These competencies improve safety and
patient outcomes.
