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 patient with pneumonia is resting in bed. The
nurse notices the patient is drowsy, reports feeling “more short
of breath,” and has an oxygen saturation of 88% on 2 L/min via
nasal cannula.
Question Stem:
What is the nurse’s best first action?
Answer Options:
A. Increase the oxygen to 6 L/min immediately
B. Assess the patient’s respiratory status and level of
consciousness
C. Notify the provider about the change in condition
D. Document the oxygen saturation and reassess in 30 minutes
Correct Answer:
B. Assess the patient’s respiratory status and level of
consciousness
Detailed Rationale:
This patient may be deteriorating. The nurse must first
recognize and assess cues before taking further action. A
focused assessment of breathing effort, lung sounds, work of
breathing, mental status, and oxygen delivery system helps
determine whether the patient needs escalation of care. This
supports safe clinical reasoning and avoids delaying the
identification of respiratory failure.
Incorrect Option Analysis:
, A is incorrect because oxygen changes should be based on
assessment and policy; blindly increasing flow may not
address the underlying problem. This reflects a cue-
response shortcut and could delay appropriate escalation.
C is incorrect because notification comes after focused
assessment unless the patient is in immediate crisis.
D is unsafe because the patient has signs of worsening
oxygenation and requires immediate reassessment, not
delayed charting.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues, Analyze Cues
Clinical Reasoning Focus:
Cue Recognition
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify the nurse’s first action when a patient shows cues of
acute respiratory deterioration.
, 2) MCQ
Clinical Scenario:
A medical-surgical unit is updating a protocol for preventing
surgical site infections. The nurse is asked which action best
reflects evidence-based practice.
Question Stem:
Which choice best demonstrates evidence-based nursing
practice?
Answer Options:
A. Following the same wound care routine that has been used
on the unit for years
B. Using a recent clinical guideline, unit data, and patient
preferences to guide wound care
C. Asking the most experienced nurse what they usually do
D. Waiting to change practice until the hospital infection rate
rises
Correct Answer:
B. Using a recent clinical guideline, unit data, and patient
preferences to guide wound care
Detailed Rationale:
Evidence-based practice combines the best available evidence,
clinical expertise, and patient values. Using current guidelines
and local outcome data improves safety and quality. Patient
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 patient with pneumonia is resting in bed. The
nurse notices the patient is drowsy, reports feeling “more short
of breath,” and has an oxygen saturation of 88% on 2 L/min via
nasal cannula.
Question Stem:
What is the nurse’s best first action?
Answer Options:
A. Increase the oxygen to 6 L/min immediately
B. Assess the patient’s respiratory status and level of
consciousness
C. Notify the provider about the change in condition
D. Document the oxygen saturation and reassess in 30 minutes
Correct Answer:
B. Assess the patient’s respiratory status and level of
consciousness
Detailed Rationale:
This patient may be deteriorating. The nurse must first
recognize and assess cues before taking further action. A
focused assessment of breathing effort, lung sounds, work of
breathing, mental status, and oxygen delivery system helps
determine whether the patient needs escalation of care. This
supports safe clinical reasoning and avoids delaying the
identification of respiratory failure.
Incorrect Option Analysis:
, A is incorrect because oxygen changes should be based on
assessment and policy; blindly increasing flow may not
address the underlying problem. This reflects a cue-
response shortcut and could delay appropriate escalation.
C is incorrect because notification comes after focused
assessment unless the patient is in immediate crisis.
D is unsafe because the patient has signs of worsening
oxygenation and requires immediate reassessment, not
delayed charting.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues, Analyze Cues
Clinical Reasoning Focus:
Cue Recognition
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Identify the nurse’s first action when a patient shows cues of
acute respiratory deterioration.
, 2) MCQ
Clinical Scenario:
A medical-surgical unit is updating a protocol for preventing
surgical site infections. The nurse is asked which action best
reflects evidence-based practice.
Question Stem:
Which choice best demonstrates evidence-based nursing
practice?
Answer Options:
A. Following the same wound care routine that has been used
on the unit for years
B. Using a recent clinical guideline, unit data, and patient
preferences to guide wound care
C. Asking the most experienced nurse what they usually do
D. Waiting to change practice until the hospital infection rate
rises
Correct Answer:
B. Using a recent clinical guideline, unit data, and patient
preferences to guide wound care
Detailed Rationale:
Evidence-based practice combines the best available evidence,
clinical expertise, and patient values. Using current guidelines
and local outcome data improves safety and quality. Patient
