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 newly admitted older adult has a respiratory rate of 28/min,
oxygen saturation of 90% on room air, and new restlessness
after receiving opioid pain medication. The nurse is reviewing
the findings before starting the admission documentation.
Question Stem:
Which action best reflects clinical reasoning in this situation?
Answer Options:
A. Document the findings and continue with the admission
assessment later
B. Compare the findings with the patient’s baseline and
reassess oxygenation immediately
C. Ask the nursing assistant to encourage the patient to drink
fluids
D. Administer the next scheduled pain dose to keep the patient
comfortable
Correct Answer:
B. Compare the findings with the patient’s baseline and
reassess oxygenation immediately
Detailed Rationale:
The nurse is recognizing abnormal cues and analyzing whether
the patient may be developing opioid-related respiratory
depression or another acute problem. Comparing current
findings with baseline and reassessing oxygenation are
appropriate first steps in clinical reasoning and patient safety.
This supports early identification of deterioration.
,Incorrect Option Analysis:
A: Delays action; respiratory compromise requires
immediate reassessment.
C: Fluids do not address the priority problem.
D: Giving another opioid could worsen respiratory status.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Analyze Cues
Clinical Reasoning Focus: Cue Recognition
Difficulty: Moderate
Bloom’s Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify early cues of deterioration and
respond with priority reassessment.
2) SATA
Clinical Scenario:
A medical-surgical unit is trying to reduce catheter-associated
urinary tract infections (CAUTIs) using evidence-based practice.
Question Stem:
Which actions are part of evidence-based practice? Select all
that apply.
Answer Options:
A. Review current clinical practice guidelines
, B. Continue the unit’s traditional catheter care routine without
change
C. Consider patient preferences and individual risk factors
D. Evaluate infection rates after the intervention
E. Follow the most experienced nurse’s opinion only
Correct Answer:
A, C, D
Detailed Rationale:
Evidence-based practice integrates the best available evidence,
clinical expertise, and patient values. Reviewing guidelines,
incorporating patient factors, and evaluating outcomes are core
EBP actions.
Incorrect Option Analysis:
B: Tradition alone is not evidence-based and may
perpetuate outdated practice.
E: Expert opinion can contribute, but it is not enough by
itself to guide practice.
Nursing Process Linkage: Planning / Evaluation
Clinical Judgment Competencies (NCJMM): Analyze Cues,
Generate Solutions, Evaluate Outcomes
Clinical Reasoning Focus: Decision-Making
Difficulty: Moderate
Bloom’s Level: Analyze
NCLEX Client Needs Category: Management of Care
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 newly admitted older adult has a respiratory rate of 28/min,
oxygen saturation of 90% on room air, and new restlessness
after receiving opioid pain medication. The nurse is reviewing
the findings before starting the admission documentation.
Question Stem:
Which action best reflects clinical reasoning in this situation?
Answer Options:
A. Document the findings and continue with the admission
assessment later
B. Compare the findings with the patient’s baseline and
reassess oxygenation immediately
C. Ask the nursing assistant to encourage the patient to drink
fluids
D. Administer the next scheduled pain dose to keep the patient
comfortable
Correct Answer:
B. Compare the findings with the patient’s baseline and
reassess oxygenation immediately
Detailed Rationale:
The nurse is recognizing abnormal cues and analyzing whether
the patient may be developing opioid-related respiratory
depression or another acute problem. Comparing current
findings with baseline and reassessing oxygenation are
appropriate first steps in clinical reasoning and patient safety.
This supports early identification of deterioration.
,Incorrect Option Analysis:
A: Delays action; respiratory compromise requires
immediate reassessment.
C: Fluids do not address the priority problem.
D: Giving another opioid could worsen respiratory status.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues,
Analyze Cues
Clinical Reasoning Focus: Cue Recognition
Difficulty: Moderate
Bloom’s Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify early cues of deterioration and
respond with priority reassessment.
2) SATA
Clinical Scenario:
A medical-surgical unit is trying to reduce catheter-associated
urinary tract infections (CAUTIs) using evidence-based practice.
Question Stem:
Which actions are part of evidence-based practice? Select all
that apply.
Answer Options:
A. Review current clinical practice guidelines
, B. Continue the unit’s traditional catheter care routine without
change
C. Consider patient preferences and individual risk factors
D. Evaluate infection rates after the intervention
E. Follow the most experienced nurse’s opinion only
Correct Answer:
A, C, D
Detailed Rationale:
Evidence-based practice integrates the best available evidence,
clinical expertise, and patient values. Reviewing guidelines,
incorporating patient factors, and evaluating outcomes are core
EBP actions.
Incorrect Option Analysis:
B: Tradition alone is not evidence-based and may
perpetuate outdated practice.
E: Expert opinion can contribute, but it is not enough by
itself to guide practice.
Nursing Process Linkage: Planning / Evaluation
Clinical Judgment Competencies (NCJMM): Analyze Cues,
Generate Solutions, Evaluate Outcomes
Clinical Reasoning Focus: Decision-Making
Difficulty: Moderate
Bloom’s Level: Analyze
NCLEX Client Needs Category: Management of Care
