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 is caring for a 72-year-old patient admitted with
community-acquired pneumonia. During assessment, the nurse
notes increasing respiratory rate, new confusion, and oxygen
saturation decreasing from 95% to 88%.
,Question Stem
Which nursing action best demonstrates clinical judgment?
Options
A. Document findings and reassess in 4 hours
B. Notify the healthcare provider after administering scheduled
medications
C. Recognize deterioration and initiate rapid assessment and
intervention
D. Wait for laboratory results before taking action
Correct Answer
C. Recognize deterioration and initiate rapid assessment and
intervention
Rationale
Clinical judgment requires recognizing cues indicating
deterioration and taking timely action. New confusion,
hypoxemia, and tachypnea suggest worsening respiratory
status and possible sepsis.
Incorrect Option Analysis
A: Delays intervention and may compromise patient safety.
B: Waiting may worsen clinical instability.
D: Clinical findings warrant immediate action before lab
confirmation.
Nursing Process Linkage
,Assessment
NCJMM Competencies
Recognize Cues, Analyze Cues, Take Action
Clinical Reasoning Focus
Cue Recognition
Difficulty
Easy
Bloom's Level
Apply
NCLEX Category
Physiological Adaptation
Key Learning Objective
Apply clinical judgment to identify early signs of patient
deterioration.
Question 2 (SATA)
Clinical Scenario
A nurse is applying the nursing process during admission
assessment.
Question Stem
Which actions are part of the assessment phase?
, Options
A. Obtain vital signs
B. Gather patient health history
C. Establish measurable goals
D. Perform physical examination
E. Prioritize nursing diagnoses
Correct Answers
A, B, D
Rationale
Assessment includes systematic collection of subjective and
objective data.
Incorrect Option Analysis
C: Planning phase.
E: Diagnosis phase.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
Clinical Reasoning Focus
Data Collection
Difficulty
Easy
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 is caring for a 72-year-old patient admitted with
community-acquired pneumonia. During assessment, the nurse
notes increasing respiratory rate, new confusion, and oxygen
saturation decreasing from 95% to 88%.
,Question Stem
Which nursing action best demonstrates clinical judgment?
Options
A. Document findings and reassess in 4 hours
B. Notify the healthcare provider after administering scheduled
medications
C. Recognize deterioration and initiate rapid assessment and
intervention
D. Wait for laboratory results before taking action
Correct Answer
C. Recognize deterioration and initiate rapid assessment and
intervention
Rationale
Clinical judgment requires recognizing cues indicating
deterioration and taking timely action. New confusion,
hypoxemia, and tachypnea suggest worsening respiratory
status and possible sepsis.
Incorrect Option Analysis
A: Delays intervention and may compromise patient safety.
B: Waiting may worsen clinical instability.
D: Clinical findings warrant immediate action before lab
confirmation.
Nursing Process Linkage
,Assessment
NCJMM Competencies
Recognize Cues, Analyze Cues, Take Action
Clinical Reasoning Focus
Cue Recognition
Difficulty
Easy
Bloom's Level
Apply
NCLEX Category
Physiological Adaptation
Key Learning Objective
Apply clinical judgment to identify early signs of patient
deterioration.
Question 2 (SATA)
Clinical Scenario
A nurse is applying the nursing process during admission
assessment.
Question Stem
Which actions are part of the assessment phase?
, Options
A. Obtain vital signs
B. Gather patient health history
C. Establish measurable goals
D. Perform physical examination
E. Prioritize nursing diagnoses
Correct Answers
A, B, D
Rationale
Assessment includes systematic collection of subjective and
objective data.
Incorrect Option Analysis
C: Planning phase.
E: Diagnosis phase.
Nursing Process Linkage
Assessment
NCJMM Competencies
Recognize Cues
Clinical Reasoning Focus
Data Collection
Difficulty
Easy
