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 newly licensed nurse is preparing to care for four assigned
patients on a medical-surgical unit. One patient has worsening
shortness of breath, one needs discharge teaching, one
,requires routine vital signs, and one is awaiting pain
reassessment after medication.
Question Stem:
Which action best demonstrates the nurse’s use of clinical
reasoning in prioritizing care?
Answer Options:
A. Complete the discharge teaching first because education
takes the most time.
B. Reassess the patient with worsening shortness of breath
immediately.
C. Delegate all routine vital signs to the unlicensed assistive
personnel.
D. Give the pain medication first because comfort is always the
priority.
Correct Answer:
B. Reassess the patient with worsening shortness of breath
immediately.
Detailed Rationale:
The nurse uses clinical reasoning to identify a possible
deterioration in airway or breathing, which is a higher priority
than teaching or routine tasks. Shortness of breath may
indicate hypoxemia, fluid overload, bronchospasm, or another
acute problem requiring immediate assessment. Safety and
physiologic stability come before education and nonurgent
activities.
,Incorrect Option Analysis:
A: Discharge teaching is important but not priority over
unstable respiratory symptoms. Common misconception:
all education should be completed early. Safety
implication: delayed assessment could miss clinical
deterioration.
C: Delegation may be appropriate for routine vital signs,
but the question asks for the best demonstration of clinical
reasoning in prioritization, not delegation alone. Safety
implication: overdelegation can distract from unstable
patients.
D: Pain management matters, but acute breathing
problems take precedence over comfort measures.
Common misconception: pain is always the top priority.
Safety implication: could delay urgent intervention.
Nursing Process Linkage:
Assessment
NCJMM Competencies:
Recognize Cues; Analyze Cues; Prioritize Hypotheses
Clinical Reasoning Focus:
Priority Setting
Difficulty Level:
Moderate
, Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Prioritize nursing actions using physiologic stability and
recognition of patient deterioration.
2) MCQ
Clinical Scenario:
A medical-surgical unit is implementing a central line care
bundle to reduce bloodstream infections.
Question Stem:
Which nurse action best reflects evidence-based practice?
Answer Options:
A. Use the same dressing change technique that has always
been used on the unit.
B. Follow the bundle components exactly as supported by
current infection-prevention evidence.
C. Modify the bundle based on each nurse’s personal
preference.
D. Teach staff to skip hand hygiene if gloves are worn.
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 newly licensed nurse is preparing to care for four assigned
patients on a medical-surgical unit. One patient has worsening
shortness of breath, one needs discharge teaching, one
,requires routine vital signs, and one is awaiting pain
reassessment after medication.
Question Stem:
Which action best demonstrates the nurse’s use of clinical
reasoning in prioritizing care?
Answer Options:
A. Complete the discharge teaching first because education
takes the most time.
B. Reassess the patient with worsening shortness of breath
immediately.
C. Delegate all routine vital signs to the unlicensed assistive
personnel.
D. Give the pain medication first because comfort is always the
priority.
Correct Answer:
B. Reassess the patient with worsening shortness of breath
immediately.
Detailed Rationale:
The nurse uses clinical reasoning to identify a possible
deterioration in airway or breathing, which is a higher priority
than teaching or routine tasks. Shortness of breath may
indicate hypoxemia, fluid overload, bronchospasm, or another
acute problem requiring immediate assessment. Safety and
physiologic stability come before education and nonurgent
activities.
,Incorrect Option Analysis:
A: Discharge teaching is important but not priority over
unstable respiratory symptoms. Common misconception:
all education should be completed early. Safety
implication: delayed assessment could miss clinical
deterioration.
C: Delegation may be appropriate for routine vital signs,
but the question asks for the best demonstration of clinical
reasoning in prioritization, not delegation alone. Safety
implication: overdelegation can distract from unstable
patients.
D: Pain management matters, but acute breathing
problems take precedence over comfort measures.
Common misconception: pain is always the top priority.
Safety implication: could delay urgent intervention.
Nursing Process Linkage:
Assessment
NCJMM Competencies:
Recognize Cues; Analyze Cues; Prioritize Hypotheses
Clinical Reasoning Focus:
Priority Setting
Difficulty Level:
Moderate
, Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Prioritize nursing actions using physiologic stability and
recognition of patient deterioration.
2) MCQ
Clinical Scenario:
A medical-surgical unit is implementing a central line care
bundle to reduce bloodstream infections.
Question Stem:
Which nurse action best reflects evidence-based practice?
Answer Options:
A. Use the same dressing change technique that has always
been used on the unit.
B. Follow the bundle components exactly as supported by
current infection-prevention evidence.
C. Modify the bundle based on each nurse’s personal
preference.
D. Teach staff to skip hand hygiene if gloves are worn.
