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 new graduate nurse is caring for a patient
admitted with pneumonia. During handoff, the nurse notices
that the oxygen saturation has dropped from 95% to 89% on 2
L/min nasal cannula, respiratory rate is 28/min, and the patient
is more restless than earlier.
,Question Stem: Which action should the nurse take first?
Answer Options:
A. Reassess the patient in 30 minutes
B. Increase oxygen to 4 L/min and notify the provider later
C. Perform a focused respiratory assessment and report the
findings using SBAR
D. Encourage the patient to use the incentive spirometer
Correct Answer: C
Detailed Rationale:
The patient is showing cues of possible respiratory
deterioration. The nurse’s first responsibility is to recognize and
analyze cues through a focused assessment, then communicate
clearly using SBAR. Restlessness, tachypnea, and falling oxygen
saturation suggest worsening oxygenation and require prompt
clinical reasoning. A focused assessment helps determine
severity, need for escalation, and whether immediate
interventions such as oxygen titration, positioning, or rapid
response activation are needed.
Incorrect Option Analysis:
A. Incorrect because delay risks missed deterioration. This
reflects underestimating early warning signs and may lead to
patient harm.
B. Incorrect because oxygen changes should be based on
assessment and facility protocol; independently increasing
oxygen without assessment may mask worsening status.
,D. Incorrect because incentive spirometry is supportive but
does not address immediate hypoxemia.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues, Analyze Cues, Take
Action
Clinical Reasoning Focus: Cue Recognition
Difficulty: Moderate
Bloom’s Level: Apply
NCLEX Client Needs: Physiological Adaptation
Key Learning Objective: Identify early signs of deterioration
and prioritize focused assessment and escalation.
2) SATA
Clinical Scenario: A nurse is reviewing evidence-based practice
for preventing catheter-associated urinary tract infections
(CAUTIs) on a medical-surgical unit.
Question Stem: Which nursing actions are consistent with a
CAUTI prevention bundle? Select all that apply.
Answer Options:
A. Maintain a closed drainage system
B. Secure the catheter to prevent traction
C. Empty the drainage bag when it becomes full to reduce
backflow
D. Remove the catheter as soon as it is no longer medically
necessary
, E. Irrigate the catheter routinely every shift
F. Keep the drainage bag above the level of the bladder
Correct Answers: A, B, D
Detailed Rationale:
CAUTI prevention bundles emphasize maintaining a sterile
closed system, preventing catheter movement/urethral
trauma, and removing the catheter as early as possible. These
actions reduce bacterial entry and infection risk.
Incorrect Option Analysis:
C. Incorrect because the bag should be emptied before it
becomes full, but “when full” suggests waiting too long and
may increase backflow risk. The misconception is that fullness is
harmless until extreme.
E. Incorrect because routine irrigation is not recommended
unless specifically ordered for obstruction or a defined
indication. Routine irrigation can break the closed system and
increase infection risk.
F. Incorrect because the drainage bag must stay below bladder
level to prevent reflux of urine and bacteria.
Nursing Process Linkage: Implementation
NCJMM Competencies: Take Action, Evaluate Outcomes
Clinical Reasoning Focus: Intervention Selection
Difficulty: Moderate
Bloom’s Level: Apply
NCLEX Client Needs: Safety and Infection Control
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 new graduate nurse is caring for a patient
admitted with pneumonia. During handoff, the nurse notices
that the oxygen saturation has dropped from 95% to 89% on 2
L/min nasal cannula, respiratory rate is 28/min, and the patient
is more restless than earlier.
,Question Stem: Which action should the nurse take first?
Answer Options:
A. Reassess the patient in 30 minutes
B. Increase oxygen to 4 L/min and notify the provider later
C. Perform a focused respiratory assessment and report the
findings using SBAR
D. Encourage the patient to use the incentive spirometer
Correct Answer: C
Detailed Rationale:
The patient is showing cues of possible respiratory
deterioration. The nurse’s first responsibility is to recognize and
analyze cues through a focused assessment, then communicate
clearly using SBAR. Restlessness, tachypnea, and falling oxygen
saturation suggest worsening oxygenation and require prompt
clinical reasoning. A focused assessment helps determine
severity, need for escalation, and whether immediate
interventions such as oxygen titration, positioning, or rapid
response activation are needed.
Incorrect Option Analysis:
A. Incorrect because delay risks missed deterioration. This
reflects underestimating early warning signs and may lead to
patient harm.
B. Incorrect because oxygen changes should be based on
assessment and facility protocol; independently increasing
oxygen without assessment may mask worsening status.
,D. Incorrect because incentive spirometry is supportive but
does not address immediate hypoxemia.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues, Analyze Cues, Take
Action
Clinical Reasoning Focus: Cue Recognition
Difficulty: Moderate
Bloom’s Level: Apply
NCLEX Client Needs: Physiological Adaptation
Key Learning Objective: Identify early signs of deterioration
and prioritize focused assessment and escalation.
2) SATA
Clinical Scenario: A nurse is reviewing evidence-based practice
for preventing catheter-associated urinary tract infections
(CAUTIs) on a medical-surgical unit.
Question Stem: Which nursing actions are consistent with a
CAUTI prevention bundle? Select all that apply.
Answer Options:
A. Maintain a closed drainage system
B. Secure the catheter to prevent traction
C. Empty the drainage bag when it becomes full to reduce
backflow
D. Remove the catheter as soon as it is no longer medically
necessary
, E. Irrigate the catheter routinely every shift
F. Keep the drainage bag above the level of the bladder
Correct Answers: A, B, D
Detailed Rationale:
CAUTI prevention bundles emphasize maintaining a sterile
closed system, preventing catheter movement/urethral
trauma, and removing the catheter as early as possible. These
actions reduce bacterial entry and infection risk.
Incorrect Option Analysis:
C. Incorrect because the bag should be emptied before it
becomes full, but “when full” suggests waiting too long and
may increase backflow risk. The misconception is that fullness is
harmless until extreme.
E. Incorrect because routine irrigation is not recommended
unless specifically ordered for obstruction or a defined
indication. Routine irrigation can break the closed system and
increase infection risk.
F. Incorrect because the drainage bag must stay below bladder
level to prevent reflux of urine and bacteria.
Nursing Process Linkage: Implementation
NCJMM Competencies: Take Action, Evaluate Outcomes
Clinical Reasoning Focus: Intervention Selection
Difficulty: Moderate
Bloom’s Level: Apply
NCLEX Client Needs: Safety and Infection Control
