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 scenario: A 68-year-old patient is 6 hours post–
abdominal surgery. The nurse notes a BP of 92/58 mmHg, HR
118 bpm, and increased serosanguineous drainage on the
dressing.
,Question stem: What is the nurse’s best first action?
Answer options:
A. Reassess the blood pressure, pulse, and surgical dressing
B. Administer the prescribed opioid analgesic
C. Encourage the patient to ambulate to prevent complications
D. Document the findings and continue the assessment later
Correct answer: A
Detailed rationale:
The patient has cues that may indicate postoperative bleeding
or fluid loss. The nurse’s first responsibility is to assess and
validate the finding before taking further action. Rechecking
vital signs and inspecting the dressing supports clinical
reasoning and helps determine urgency. This is aligned with the
assessment phase of the nursing process and the NCJMM
competency of Recognize Cues.
Incorrect option analysis:
B: Pain control is important, but analgesia does not
address the possible hemodynamic instability. This reflects
premature treatment. Safety risk: delayed recognition of
bleeding.
C: Ambulation is not appropriate when the patient may be
unstable. Misconception: assuming all postop patients
should mobilize regardless of cues.
, D: Deferring action risks missing deterioration.
Misconception: documentation substitutes for
assessment.
Nursing process linkage: Assessment
NCJMM competencies: Recognize Cues, Analyze Cues
Clinical reasoning focus: Cue recognition
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Physiological Adaptation
Key learning objective: Identify early signs of postoperative
instability and prioritize immediate assessment.
2) SATA
Clinical scenario: A med-surg unit is updating wound care
practice based on current evidence.
Question stem: Which nursing actions reflect evidence-
informed practice? Select all that apply.
Answer options:
A. Using a facility-approved care bundle for pressure injury
prevention
B. Choosing a dressing because “we have always used it”
C. Reviewing a recent systematic review before changing care
D. Incorporating the patient’s preferences and values into the
plan
E. Evaluating outcomes after implementing the new practice
, Correct answers: A, C, D, E
Detailed rationale:
Evidence-informed practice combines best available research,
clinical expertise, and patient preferences. Care bundles
standardize evidence-based steps. Systematic reviews
strengthen decision-making. Patient values matter because
care must be patient-centered. Evaluation confirms whether
the intervention worked.
Incorrect option analysis:
B: Tradition alone is not evidence. Misconception:
familiarity equals effectiveness. Safety risk: continued use
of outdated or ineffective care.
Nursing process linkage: Planning, Implementation, Evaluation
NCJMM competencies: Prioritize Hypotheses, Generate
Solutions, Evaluate Outcomes
Clinical reasoning focus: Data interpretation and intervention
selection
Difficulty: Moderate
Bloom’s level: Analyze
NCLEX client needs: Management of Care
Key learning objective: Distinguish evidence-based practice
from habit-based practice and integrate patient-centered
decision-making.
3) MCQ
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 scenario: A 68-year-old patient is 6 hours post–
abdominal surgery. The nurse notes a BP of 92/58 mmHg, HR
118 bpm, and increased serosanguineous drainage on the
dressing.
,Question stem: What is the nurse’s best first action?
Answer options:
A. Reassess the blood pressure, pulse, and surgical dressing
B. Administer the prescribed opioid analgesic
C. Encourage the patient to ambulate to prevent complications
D. Document the findings and continue the assessment later
Correct answer: A
Detailed rationale:
The patient has cues that may indicate postoperative bleeding
or fluid loss. The nurse’s first responsibility is to assess and
validate the finding before taking further action. Rechecking
vital signs and inspecting the dressing supports clinical
reasoning and helps determine urgency. This is aligned with the
assessment phase of the nursing process and the NCJMM
competency of Recognize Cues.
Incorrect option analysis:
B: Pain control is important, but analgesia does not
address the possible hemodynamic instability. This reflects
premature treatment. Safety risk: delayed recognition of
bleeding.
C: Ambulation is not appropriate when the patient may be
unstable. Misconception: assuming all postop patients
should mobilize regardless of cues.
, D: Deferring action risks missing deterioration.
Misconception: documentation substitutes for
assessment.
Nursing process linkage: Assessment
NCJMM competencies: Recognize Cues, Analyze Cues
Clinical reasoning focus: Cue recognition
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Physiological Adaptation
Key learning objective: Identify early signs of postoperative
instability and prioritize immediate assessment.
2) SATA
Clinical scenario: A med-surg unit is updating wound care
practice based on current evidence.
Question stem: Which nursing actions reflect evidence-
informed practice? Select all that apply.
Answer options:
A. Using a facility-approved care bundle for pressure injury
prevention
B. Choosing a dressing because “we have always used it”
C. Reviewing a recent systematic review before changing care
D. Incorporating the patient’s preferences and values into the
plan
E. Evaluating outcomes after implementing the new practice
, Correct answers: A, C, D, E
Detailed rationale:
Evidence-informed practice combines best available research,
clinical expertise, and patient preferences. Care bundles
standardize evidence-based steps. Systematic reviews
strengthen decision-making. Patient values matter because
care must be patient-centered. Evaluation confirms whether
the intervention worked.
Incorrect option analysis:
B: Tradition alone is not evidence. Misconception:
familiarity equals effectiveness. Safety risk: continued use
of outdated or ineffective care.
Nursing process linkage: Planning, Implementation, Evaluation
NCJMM competencies: Prioritize Hypotheses, Generate
Solutions, Evaluate Outcomes
Clinical reasoning focus: Data interpretation and intervention
selection
Difficulty: Moderate
Bloom’s level: Analyze
NCLEX client needs: Management of Care
Key learning objective: Distinguish evidence-based practice
from habit-based practice and integrate patient-centered
decision-making.
3) MCQ
