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 adult patient is due for an IV antibiotic. The
nurse notices that the patient has a wristband, but the name on
the MAR differs slightly from the name the patient gave during
handoff.
Question stem:
What is the nurse’s best action?
Answer options:
A. Administer the antibiotic because the wristband is present.
B. Verify the patient’s identity using two identifiers before
giving the medication.
C. Ask the family member in the room to confirm the patient’s
identity.
D. Delay the medication until the next shift.
Correct answer:
B
Detailed rationale:
Safe medication administration begins with correct patient
identification using two identifiers (for example, name and
date of birth). This prevents wrong-patient errors and reflects
patient safety, quality care, and evidence-based nursing
practice.
Incorrect option analysis:
A: Wrong because a wristband alone is not enough; this is
a common safety misconception.
, C: Family confirmation is not a reliable identifier and
increases error risk.
D: Delaying care does not solve the identity discrepancy
and may harm the patient.
Nursing process link:
Assessment
NCJMM competencies:
Recognize Cues; Take Action
Clinical reasoning focus:
Cue Recognition
Difficulty level:
Easy
Bloom’s cognitive level:
Apply
NCLEX client needs category:
Safety and Infection Control
Key learning objective:
Apply safe patient-identification practices before medication
administration.
2) MCQ
Clinical scenario:
A postoperative patient says, “I feel short of breath when I walk
, to the bathroom.” The nurse sees that the patient’s respiratory
rate is slightly elevated.
Question stem:
What should the nurse do first?
Answer options:
A. Document the finding and reassess in 1 hour.
B. Assess oxygen saturation and lung sounds.
C. Notify the provider immediately.
D. Encourage the patient to walk more to build endurance.
Correct answer:
B
Detailed rationale:
The nurse should first assess for worsening respiratory
compromise. Respiratory rate, oxygen saturation, and lung
sounds help determine severity before escalation or
intervention. Assessment comes before diagnosis or provider
notification unless the patient is in immediate danger.
Incorrect option analysis:
A: Delays assessment of a potentially worsening condition.
C: Provider notification may be needed, but not before
obtaining more data.
D: This is unsafe until the cause of dyspnea is understood.
Nursing process link:
Assessment
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 adult patient is due for an IV antibiotic. The
nurse notices that the patient has a wristband, but the name on
the MAR differs slightly from the name the patient gave during
handoff.
Question stem:
What is the nurse’s best action?
Answer options:
A. Administer the antibiotic because the wristband is present.
B. Verify the patient’s identity using two identifiers before
giving the medication.
C. Ask the family member in the room to confirm the patient’s
identity.
D. Delay the medication until the next shift.
Correct answer:
B
Detailed rationale:
Safe medication administration begins with correct patient
identification using two identifiers (for example, name and
date of birth). This prevents wrong-patient errors and reflects
patient safety, quality care, and evidence-based nursing
practice.
Incorrect option analysis:
A: Wrong because a wristband alone is not enough; this is
a common safety misconception.
, C: Family confirmation is not a reliable identifier and
increases error risk.
D: Delaying care does not solve the identity discrepancy
and may harm the patient.
Nursing process link:
Assessment
NCJMM competencies:
Recognize Cues; Take Action
Clinical reasoning focus:
Cue Recognition
Difficulty level:
Easy
Bloom’s cognitive level:
Apply
NCLEX client needs category:
Safety and Infection Control
Key learning objective:
Apply safe patient-identification practices before medication
administration.
2) MCQ
Clinical scenario:
A postoperative patient says, “I feel short of breath when I walk
, to the bathroom.” The nurse sees that the patient’s respiratory
rate is slightly elevated.
Question stem:
What should the nurse do first?
Answer options:
A. Document the finding and reassess in 1 hour.
B. Assess oxygen saturation and lung sounds.
C. Notify the provider immediately.
D. Encourage the patient to walk more to build endurance.
Correct answer:
B
Detailed rationale:
The nurse should first assess for worsening respiratory
compromise. Respiratory rate, oxygen saturation, and lung
sounds help determine severity before escalation or
intervention. Assessment comes before diagnosis or provider
notification unless the patient is in immediate danger.
Incorrect option analysis:
A: Delays assessment of a potentially worsening condition.
C: Provider notification may be needed, but not before
obtaining more data.
D: This is unsafe until the cause of dyspnea is understood.
Nursing process link:
Assessment
