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 72-year-old patient is 4 hours post–
abdominal surgery. The nurse notes the patient is difficult to
,arouse, respirations are 10/min, and SpO₂ is 88% on 2 L/min
nasal cannula.
Question Stem: What is the nurse’s priority action?
Answer Options:
A. Administer the prescribed opioid for pain relief
B. Reassess the patient in 15 minutes
C. Activate the rapid response process and remain with the
patient
D. Document the findings and continue routine monitoring
Correct Answer: C
Detailed Rationale:
The patient shows acute deterioration with hypoventilation
and hypoxemia, suggesting possible opioid effect, airway
compromise, or postoperative respiratory depression. The
priority is to recognize cues, take immediate action, and
summon help. Rapid response activation supports timely
intervention and patient safety.
Incorrect Option Analysis:
A: Opioids may worsen respiratory depression; this
reflects a common misconception that pain management
should precede airway concerns. Unsafe.
B: Delaying reassessment risks respiratory arrest.
D: Documentation is necessary, but not before stabilizing
the patient.
,Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues, Analyze Cues,
Prioritize Hypotheses, Take Action
Clinical Reasoning Focus: Cue recognition / priority setting
Difficulty Level: Difficult
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify and respond to signs of
postoperative respiratory compromise using clinical judgment.
2) SATA
Clinical Scenario: A nurse on a medical-surgical unit is teaching
a new graduate about professional boundaries and privacy.
Question Stem: Which actions demonstrate a breach of
professional boundaries or privacy? Select all that apply.
Answer Options:
A. Texting a patient update from the nurse’s personal phone
B. Accepting a patient’s expensive gift after discharge
C. Discussing a patient’s diagnosis in the elevator
D. Posting a unit photo with no patient identifiers
E. Adding a current patient on social media
Correct Answers: A, B, C, E
Detailed Rationale:
Professional boundaries and privacy rules require nurses to
maintain therapeutic relationships and protect patient
, information. Personal phones, gifts, public conversations, and
social media connections can create boundary crossings,
confidentiality risks, or perceived favoritism.
Incorrect Option Analysis:
D: A unit photo without patient identifiers may still violate
policy if taken in a clinical area, but the option as written
does not clearly show a privacy breach. In exam settings,
this is the least clearly unsafe choice.
A: Breach of privacy/boundaries; common misconception
is that “just a quick text” is harmless.
B: Gifts can create dependency or favoritism.
C: Public disclosure of patient information violates
confidentiality.
E: Social media contact blurs professional boundaries and
may expose protected information.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues, Analyze Cues, Take
Action
Clinical Reasoning Focus: Safety and legal/ethical decision-
making
Difficulty Level: Moderate
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Safety and Infection Control
Key Learning Objective: Apply privacy, professionalism, and
boundary standards in med-surg practice.
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 72-year-old patient is 4 hours post–
abdominal surgery. The nurse notes the patient is difficult to
,arouse, respirations are 10/min, and SpO₂ is 88% on 2 L/min
nasal cannula.
Question Stem: What is the nurse’s priority action?
Answer Options:
A. Administer the prescribed opioid for pain relief
B. Reassess the patient in 15 minutes
C. Activate the rapid response process and remain with the
patient
D. Document the findings and continue routine monitoring
Correct Answer: C
Detailed Rationale:
The patient shows acute deterioration with hypoventilation
and hypoxemia, suggesting possible opioid effect, airway
compromise, or postoperative respiratory depression. The
priority is to recognize cues, take immediate action, and
summon help. Rapid response activation supports timely
intervention and patient safety.
Incorrect Option Analysis:
A: Opioids may worsen respiratory depression; this
reflects a common misconception that pain management
should precede airway concerns. Unsafe.
B: Delaying reassessment risks respiratory arrest.
D: Documentation is necessary, but not before stabilizing
the patient.
,Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues, Analyze Cues,
Prioritize Hypotheses, Take Action
Clinical Reasoning Focus: Cue recognition / priority setting
Difficulty Level: Difficult
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify and respond to signs of
postoperative respiratory compromise using clinical judgment.
2) SATA
Clinical Scenario: A nurse on a medical-surgical unit is teaching
a new graduate about professional boundaries and privacy.
Question Stem: Which actions demonstrate a breach of
professional boundaries or privacy? Select all that apply.
Answer Options:
A. Texting a patient update from the nurse’s personal phone
B. Accepting a patient’s expensive gift after discharge
C. Discussing a patient’s diagnosis in the elevator
D. Posting a unit photo with no patient identifiers
E. Adding a current patient on social media
Correct Answers: A, B, C, E
Detailed Rationale:
Professional boundaries and privacy rules require nurses to
maintain therapeutic relationships and protect patient
, information. Personal phones, gifts, public conversations, and
social media connections can create boundary crossings,
confidentiality risks, or perceived favoritism.
Incorrect Option Analysis:
D: A unit photo without patient identifiers may still violate
policy if taken in a clinical area, but the option as written
does not clearly show a privacy breach. In exam settings,
this is the least clearly unsafe choice.
A: Breach of privacy/boundaries; common misconception
is that “just a quick text” is harmless.
B: Gifts can create dependency or favoritism.
C: Public disclosure of patient information violates
confidentiality.
E: Social media contact blurs professional boundaries and
may expose protected information.
Nursing Process Linkage: Implementation
NCJMM Competencies: Recognize Cues, Analyze Cues, Take
Action
Clinical Reasoning Focus: Safety and legal/ethical decision-
making
Difficulty Level: Moderate
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Safety and Infection Control
Key Learning Objective: Apply privacy, professionalism, and
boundary standards in med-surg practice.
