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
Scenario: A 68-year-old patient is postoperative day 1 after a
bowel resection. During shift report, the RN notes blood
pressure 92/54 mm Hg, heart rate 118/min, urine output 20
mL/hr, and the patient was oriented earlier but is now slower
,to respond.
Stem: What is the nurse’s best first action?
Options:
A. Assess the surgical incision, drain output, and compare
current findings with baseline
B. Administer the prescribed PRN pain medication
C. Encourage early ambulation to prevent complications
D. Document the findings and reassess in 4 hours
Correct Answer: A
Rationale: The patient shows early cues of possible
hypovolemia, bleeding, or deterioration. The nurse should first
assess for additional data before acting further. Comparing
current findings with baseline, checking the incision and drain
output, and trending vital signs supports clinical reasoning and
rapid identification of a deteriorating postoperative patient.
Incorrect Option Analysis:
B. Pain medication may mask worsening instability and delays
assessment.
C. Ambulation is beneficial when stable, but this patient needs
immediate assessment first.
D. Waiting is unsafe because the cues suggest possible acute
decline.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues; Analyze Cues
Clinical Reasoning Focus: Cue Recognition
Difficulty: Moderate
,Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation
Key Learning Objective: Identify early signs of postoperative
deterioration and prioritize assessment.
2. SATA
Scenario: A medical-surgical unit is implementing a central line
infection-prevention bundle.
Stem: Which interventions are appropriate parts of the
evidence-based bundle? Select all that apply.
Options:
A. Perform hand hygiene before any line manipulation
B. Use chlorhexidine skin antisepsis during dressing changes
C. Change central line dressings every 24 hours regardless of
condition
D. Scrub the hub before accessing the line
E. Assess daily whether the central line is still needed
Correct Answers: A, B, D, E
Rationale: Central line bundles reduce infection by combining
proven measures: hand hygiene, chlorhexidine antisepsis, hub
disinfection, and daily review of line necessity. These actions
decrease contamination risk and unnecessary device exposure.
Incorrect Option Analysis:
C. Routine daily dressing changes are not indicated unless the
, dressing is soiled, loose, or per policy; unnecessary
manipulation increases infection risk.
Nursing Process Linkage: Implementation
NCJMM Competencies: Generate Solutions; Take Action;
Evaluate Outcomes
Clinical Reasoning Focus: Intervention Selection
Difficulty: Moderate
Bloom’s Level: Apply
NCLEX Client Needs: Safety and Infection Control
Key Learning Objective: Select evidence-based interventions
that reduce device-related infection risk.
3. MCQ
Scenario: The nurse assesses a patient with bilateral ankle
edema, crackles in both lung bases, and a 2-kg weight gain in 2
days.
Stem: Which nursing process step is the nurse using when
identifying “excess fluid volume”?
Options:
A. Assessment
B. Nursing diagnosis
C. Planning
D. Evaluation
Correct Answer: B
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
1. MCQ
Scenario: A 68-year-old patient is postoperative day 1 after a
bowel resection. During shift report, the RN notes blood
pressure 92/54 mm Hg, heart rate 118/min, urine output 20
mL/hr, and the patient was oriented earlier but is now slower
,to respond.
Stem: What is the nurse’s best first action?
Options:
A. Assess the surgical incision, drain output, and compare
current findings with baseline
B. Administer the prescribed PRN pain medication
C. Encourage early ambulation to prevent complications
D. Document the findings and reassess in 4 hours
Correct Answer: A
Rationale: The patient shows early cues of possible
hypovolemia, bleeding, or deterioration. The nurse should first
assess for additional data before acting further. Comparing
current findings with baseline, checking the incision and drain
output, and trending vital signs supports clinical reasoning and
rapid identification of a deteriorating postoperative patient.
Incorrect Option Analysis:
B. Pain medication may mask worsening instability and delays
assessment.
C. Ambulation is beneficial when stable, but this patient needs
immediate assessment first.
D. Waiting is unsafe because the cues suggest possible acute
decline.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues; Analyze Cues
Clinical Reasoning Focus: Cue Recognition
Difficulty: Moderate
,Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation
Key Learning Objective: Identify early signs of postoperative
deterioration and prioritize assessment.
2. SATA
Scenario: A medical-surgical unit is implementing a central line
infection-prevention bundle.
Stem: Which interventions are appropriate parts of the
evidence-based bundle? Select all that apply.
Options:
A. Perform hand hygiene before any line manipulation
B. Use chlorhexidine skin antisepsis during dressing changes
C. Change central line dressings every 24 hours regardless of
condition
D. Scrub the hub before accessing the line
E. Assess daily whether the central line is still needed
Correct Answers: A, B, D, E
Rationale: Central line bundles reduce infection by combining
proven measures: hand hygiene, chlorhexidine antisepsis, hub
disinfection, and daily review of line necessity. These actions
decrease contamination risk and unnecessary device exposure.
Incorrect Option Analysis:
C. Routine daily dressing changes are not indicated unless the
, dressing is soiled, loose, or per policy; unnecessary
manipulation increases infection risk.
Nursing Process Linkage: Implementation
NCJMM Competencies: Generate Solutions; Take Action;
Evaluate Outcomes
Clinical Reasoning Focus: Intervention Selection
Difficulty: Moderate
Bloom’s Level: Apply
NCLEX Client Needs: Safety and Infection Control
Key Learning Objective: Select evidence-based interventions
that reduce device-related infection risk.
3. MCQ
Scenario: The nurse assesses a patient with bilateral ankle
edema, crackles in both lung bases, and a 2-kg weight gain in 2
days.
Stem: Which nursing process step is the nurse using when
identifying “excess fluid volume”?
Options:
A. Assessment
B. Nursing diagnosis
C. Planning
D. Evaluation
Correct Answer: B
