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 nurse is receiving handoff on four adult patients. One patient
is newly confused and has oxygen saturation of 88% on room
air. Another reports pain of 7/10, another is waiting for
,discharge teaching, and another needs a routine dressing
change.
Question Stem:
Which patient should the nurse assess first?
Answer Options:
A. The patient reporting pain of 7/10
B. The patient who needs discharge teaching
C. The patient with new confusion and oxygen saturation of
88%
D. The patient needing a routine dressing change
Correct Answer:
C
Detailed Rationale:
New confusion plus hypoxemia suggests impaired oxygenation
and possible acute deterioration. In clinical reasoning, the
nurse prioritizes cues that threaten airway/breathing and
neurologic stability. The situation requires immediate
assessment and intervention.
Incorrect Option Analysis:
A: Pain is important but is not the most urgent threat in
this set. Common misconception: treating the loudest
symptom first rather than the most dangerous one.
B: Discharge teaching can wait until the patient is stable.
Safety risk: delayed recognition of deterioration.
, D: A routine dressing change is lower priority than a new
change in cognition and oxygenation.
C: Correct because it reflects cue recognition and priority
setting for potential hypoxia.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues, Analyze Cues,
Prioritize Hypotheses
Clinical Reasoning Focus: Priority Setting
Difficulty: Moderate
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation
Key Learning Objective: Identify signs of possible deterioration
and prioritize immediate assessment.
2. MCQ
Clinical Scenario:
A nurse reviews a unit protocol for preventing catheter-
associated urinary tract infections (CAUTIs). The protocol
includes catheter necessity review, hand hygiene, and aseptic
insertion technique.
Question Stem:
Which statement best reflects evidence-based practice?
Answer Options:
A. “I will follow the protocol because it is the same one we have
always used.”
, B. “I will use the protocol because it integrates current
evidence, clinical expertise, and patient needs.”
C. “I will use the protocol only if the charge nurse prefers it.”
D. “I will use the protocol because it is faster than other
methods.”
Correct Answer:
B
Detailed Rationale:
Evidence-based practice combines best available evidence,
clinical expertise, and patient values/preferences. The CAUTI
bundle is an example of evidence-informed care aimed at
improving outcomes and reducing harm.
Incorrect Option Analysis:
A: Tradition alone is not evidence-based practice.
Misconception: long-standing practice equals best
practice.
C: Preference alone does not establish validity or safety.
D: Speed is not the standard; effectiveness and safety are.
B: Correct because it accurately defines EBP.
Nursing Process Linkage: Planning
NCJMM Competencies: Generate Solutions, Take Action
Clinical Reasoning Focus: Intervention Selection
Difficulty: Easy
Bloom’s Level: Understand
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 nurse is receiving handoff on four adult patients. One patient
is newly confused and has oxygen saturation of 88% on room
air. Another reports pain of 7/10, another is waiting for
,discharge teaching, and another needs a routine dressing
change.
Question Stem:
Which patient should the nurse assess first?
Answer Options:
A. The patient reporting pain of 7/10
B. The patient who needs discharge teaching
C. The patient with new confusion and oxygen saturation of
88%
D. The patient needing a routine dressing change
Correct Answer:
C
Detailed Rationale:
New confusion plus hypoxemia suggests impaired oxygenation
and possible acute deterioration. In clinical reasoning, the
nurse prioritizes cues that threaten airway/breathing and
neurologic stability. The situation requires immediate
assessment and intervention.
Incorrect Option Analysis:
A: Pain is important but is not the most urgent threat in
this set. Common misconception: treating the loudest
symptom first rather than the most dangerous one.
B: Discharge teaching can wait until the patient is stable.
Safety risk: delayed recognition of deterioration.
, D: A routine dressing change is lower priority than a new
change in cognition and oxygenation.
C: Correct because it reflects cue recognition and priority
setting for potential hypoxia.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues, Analyze Cues,
Prioritize Hypotheses
Clinical Reasoning Focus: Priority Setting
Difficulty: Moderate
Bloom’s Level: Analyze
NCLEX Client Needs: Physiological Adaptation
Key Learning Objective: Identify signs of possible deterioration
and prioritize immediate assessment.
2. MCQ
Clinical Scenario:
A nurse reviews a unit protocol for preventing catheter-
associated urinary tract infections (CAUTIs). The protocol
includes catheter necessity review, hand hygiene, and aseptic
insertion technique.
Question Stem:
Which statement best reflects evidence-based practice?
Answer Options:
A. “I will follow the protocol because it is the same one we have
always used.”
, B. “I will use the protocol because it integrates current
evidence, clinical expertise, and patient needs.”
C. “I will use the protocol only if the charge nurse prefers it.”
D. “I will use the protocol because it is faster than other
methods.”
Correct Answer:
B
Detailed Rationale:
Evidence-based practice combines best available evidence,
clinical expertise, and patient values/preferences. The CAUTI
bundle is an example of evidence-informed care aimed at
improving outcomes and reducing harm.
Incorrect Option Analysis:
A: Tradition alone is not evidence-based practice.
Misconception: long-standing practice equals best
practice.
C: Preference alone does not establish validity or safety.
D: Speed is not the standard; effectiveness and safety are.
B: Correct because it accurately defines EBP.
Nursing Process Linkage: Planning
NCJMM Competencies: Generate Solutions, Take Action
Clinical Reasoning Focus: Intervention Selection
Difficulty: Easy
Bloom’s Level: Understand
