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) Multiple-Choice Question (MCQ)
Clinical scenario: A newly licensed nurse is preparing to care for
a postoperative patient and asks the charge nurse, “What
should I be focusing on first during my shift?”
Question stem: Which action best reflects the nurse’s use of
clinical reasoning in medical-surgical practice?
,Answer options:
A. Documenting all care completed at the end of the shift
B. Recognizing relevant patient cues, interpreting their
meaning, and selecting the safest response
C. Following unit routines exactly as written
D. Waiting for the provider to identify every needed
intervention
Correct answer: B
Detailed rationale: Clinical reasoning is the deliberate,
systematic process of recognizing cues, analyzing information,
prioritizing concerns, and choosing actions that promote safe
patient care. In medical-surgical nursing, this includes noticing
abnormal assessment findings, connecting them to possible
complications, and responding promptly. Option B captures the
full reasoning cycle.
A is important, but documentation is not clinical
reasoning.
C reflects task compliance, not judgment.
D delays independent nursing action and weakens patient
safety.
Incorrect option analysis:
A: Incorrect; it represents record keeping, not reasoning. It
may reflect a misconception that nursing is primarily
charting. Risk: delayed recognition of deterioration if
thinking is postponed.
, C: Incorrect; routines are helpful, but reasoning requires
adapting care to the patient. Misconception: “good
nursing means always following the routine.” Risk: missed
cues.
D: Incorrect; nurses must independently assess and act
within scope. Misconception: the provider is the sole
decision-maker. Risk: unsafe delays.
Nursing process linkage: Assessment
NCJMM competencies: Recognize Cues; Analyze Cues;
Prioritize Hypotheses; Take Action
Clinical reasoning focus: Cue Recognition
Difficulty: Easy
Bloom’s level: Understand
NCLEX client needs category: Management of Care
Key learning objective: Identify clinical reasoning as the
foundation for safe nursing judgment and action.
2) Select-All-That-Apply (SATA)
Clinical scenario: A nurse is completing an admission
assessment on an adult medical-surgical patient.
Question stem: Which findings are assessment data rather
than nursing diagnoses or interventions?
Select all that apply.
, Answer options:
A. Respiratory rate of 28/min
B. Risk for impaired skin integrity
C. Patient states, “I feel dizzy when I stand.”
D. Turning the patient every 2 hours
E. Blood pressure of 88/54 mm Hg
F. Acute pain related to tissue injury
Correct answers: A, C, E
Detailed rationale: Assessment data are objective or subjective
cues collected from the patient or environment. Respiratory
rate, patient-reported dizziness, and low blood pressure are
assessment findings.
B and F are nursing diagnoses.
D is an intervention.
Incorrect option analysis:
B: Incorrect; this is a diagnosis formed after analysis.
Misconception: risk statements are assessment data. Risk:
incomplete care planning.
D: Incorrect; this is an intervention. Misconception:
actions are assessment findings. Risk: confusion about the
nursing process.
F: Incorrect; this is a diagnosis, not raw data.
Misconception: labeling a problem is the same as assessing
it. Risk: premature conclusions.
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
1) Multiple-Choice Question (MCQ)
Clinical scenario: A newly licensed nurse is preparing to care for
a postoperative patient and asks the charge nurse, “What
should I be focusing on first during my shift?”
Question stem: Which action best reflects the nurse’s use of
clinical reasoning in medical-surgical practice?
,Answer options:
A. Documenting all care completed at the end of the shift
B. Recognizing relevant patient cues, interpreting their
meaning, and selecting the safest response
C. Following unit routines exactly as written
D. Waiting for the provider to identify every needed
intervention
Correct answer: B
Detailed rationale: Clinical reasoning is the deliberate,
systematic process of recognizing cues, analyzing information,
prioritizing concerns, and choosing actions that promote safe
patient care. In medical-surgical nursing, this includes noticing
abnormal assessment findings, connecting them to possible
complications, and responding promptly. Option B captures the
full reasoning cycle.
A is important, but documentation is not clinical
reasoning.
C reflects task compliance, not judgment.
D delays independent nursing action and weakens patient
safety.
Incorrect option analysis:
A: Incorrect; it represents record keeping, not reasoning. It
may reflect a misconception that nursing is primarily
charting. Risk: delayed recognition of deterioration if
thinking is postponed.
, C: Incorrect; routines are helpful, but reasoning requires
adapting care to the patient. Misconception: “good
nursing means always following the routine.” Risk: missed
cues.
D: Incorrect; nurses must independently assess and act
within scope. Misconception: the provider is the sole
decision-maker. Risk: unsafe delays.
Nursing process linkage: Assessment
NCJMM competencies: Recognize Cues; Analyze Cues;
Prioritize Hypotheses; Take Action
Clinical reasoning focus: Cue Recognition
Difficulty: Easy
Bloom’s level: Understand
NCLEX client needs category: Management of Care
Key learning objective: Identify clinical reasoning as the
foundation for safe nursing judgment and action.
2) Select-All-That-Apply (SATA)
Clinical scenario: A nurse is completing an admission
assessment on an adult medical-surgical patient.
Question stem: Which findings are assessment data rather
than nursing diagnoses or interventions?
Select all that apply.
, Answer options:
A. Respiratory rate of 28/min
B. Risk for impaired skin integrity
C. Patient states, “I feel dizzy when I stand.”
D. Turning the patient every 2 hours
E. Blood pressure of 88/54 mm Hg
F. Acute pain related to tissue injury
Correct answers: A, C, E
Detailed rationale: Assessment data are objective or subjective
cues collected from the patient or environment. Respiratory
rate, patient-reported dizziness, and low blood pressure are
assessment findings.
B and F are nursing diagnoses.
D is an intervention.
Incorrect option analysis:
B: Incorrect; this is a diagnosis formed after analysis.
Misconception: risk statements are assessment data. Risk:
incomplete care planning.
D: Incorrect; this is an intervention. Misconception:
actions are assessment findings. Risk: confusion about the
nursing process.
F: Incorrect; this is a diagnosis, not raw data.
Misconception: labeling a problem is the same as assessing
it. Risk: premature conclusions.
