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
Question 1 (MCQ)
Clinical Scenario
A nurse begins a shift caring for a patient admitted with
worsening heart failure. During assessment, the nurse notes
increasing shortness of breath, bilateral crackles, and a 2-kg
weight gain since yesterday.
,Question Stem
Which action best demonstrates the nurse's use of clinical
reasoning?
Options
A. Document the findings and continue routine care.
B. Recognize the findings as evidence of fluid overload and
notify the provider.
C. Compare findings with another patient on the unit.
D. Review the patient's discharge instructions.
Correct Answer
B. Recognize the findings as evidence of fluid overload and
notify the provider.
Detailed Rationale
Clinical reasoning requires collecting cues, interpreting their
significance, and taking action. The assessment findings suggest
worsening fluid volume excess and possible decompensated
heart failure. Prompt recognition and communication support
patient safety and prevent deterioration.
Incorrect Option Analysis
A: Fails to act on significant findings; may delay treatment.
C: Comparison with another patient does not address the
patient's condition.
,D: Discharge teaching is premature and does not address the
immediate concern.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
Analyze Cues
Take Action
Clinical Reasoning Focus
Cue Recognition
Difficulty
Easy
Bloom's Level
Apply
NCLEX Client Needs
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning to identify patient deterioration.
Question 2 (SATA)
, Clinical Scenario
A nurse is evaluating whether care provided aligns with Quality
and Safety Education for Nurses (QSEN) competencies.
Question Stem
Which nursing actions support safe and effective healthcare?
Select all that apply.
Options
A. Using evidence-based interventions
B. Reporting near-miss events
C. Ignoring patient preferences when planning care
D. Collaborating with interprofessional team members
E. Using electronic health records accurately
F. Delegating without follow-up
Correct Answers
A, B, D, E
Detailed Rationale
Core competencies include evidence-based practice, quality
improvement, teamwork, informatics, and patient-centered
care.
Incorrect Option Analysis
C: Violates patient-centered care principles.
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
Question 1 (MCQ)
Clinical Scenario
A nurse begins a shift caring for a patient admitted with
worsening heart failure. During assessment, the nurse notes
increasing shortness of breath, bilateral crackles, and a 2-kg
weight gain since yesterday.
,Question Stem
Which action best demonstrates the nurse's use of clinical
reasoning?
Options
A. Document the findings and continue routine care.
B. Recognize the findings as evidence of fluid overload and
notify the provider.
C. Compare findings with another patient on the unit.
D. Review the patient's discharge instructions.
Correct Answer
B. Recognize the findings as evidence of fluid overload and
notify the provider.
Detailed Rationale
Clinical reasoning requires collecting cues, interpreting their
significance, and taking action. The assessment findings suggest
worsening fluid volume excess and possible decompensated
heart failure. Prompt recognition and communication support
patient safety and prevent deterioration.
Incorrect Option Analysis
A: Fails to act on significant findings; may delay treatment.
C: Comparison with another patient does not address the
patient's condition.
,D: Discharge teaching is premature and does not address the
immediate concern.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
Analyze Cues
Take Action
Clinical Reasoning Focus
Cue Recognition
Difficulty
Easy
Bloom's Level
Apply
NCLEX Client Needs
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning to identify patient deterioration.
Question 2 (SATA)
, Clinical Scenario
A nurse is evaluating whether care provided aligns with Quality
and Safety Education for Nurses (QSEN) competencies.
Question Stem
Which nursing actions support safe and effective healthcare?
Select all that apply.
Options
A. Using evidence-based interventions
B. Reporting near-miss events
C. Ignoring patient preferences when planning care
D. Collaborating with interprofessional team members
E. Using electronic health records accurately
F. Delegating without follow-up
Correct Answers
A, B, D, E
Detailed Rationale
Core competencies include evidence-based practice, quality
improvement, teamwork, informatics, and patient-centered
care.
Incorrect Option Analysis
C: Violates patient-centered care principles.
