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
Clinical Scenario: A new graduate nurse is caring for a
postoperative patient who was alert and comfortable 30
minutes ago. The patient is now restless, repeatedly removing
,the oxygen cannula, and says, “Something feels wrong.” Heart
rate is 118/min, respiratory rate is 24/min, blood pressure is
98/60 mm Hg.
Question Stem: What is the nurse’s best first action?
Answer Options:
A. Document the changes and reassess after medication pass
B. Assess airway, breathing, circulation, and compare the
findings with baseline
C. Offer water and ask the patient to rest
D. Ask the nursing assistant to stay with the patient while the
nurse continues rounds
Correct Answer: B
Detailed Rationale: The patient is showing early deterioration
cues. The safest first step is immediate assessment of airway,
breathing, circulation, and comparison with baseline data. This
reflects clinical judgment by recognizing and analyzing cues
before acting.
Incorrect Option Analysis:
A: Incorrect because documentation without assessment
delays care. Misconception: “wait and see.” Safety risk:
missed deterioration.
C: Incorrect because hydration is not the priority before
assessing instability. Misconception: assuming anxiety or
thirst. Safety risk: delayed response to hypoxia/shock.
, D: Incorrect because support staff should not be left to
monitor a potentially unstable patient without RN
assessment. Misconception: delegating the problem
instead of assessing it. Safety risk: missed escalation.
Nursing Process Linkage: Assessment
NCJMM Competencies: 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 early instability cues that
require immediate RN assessment.
2) MCQ
Clinical Scenario: A patient receiving furosemide has blood
pressure 86/54 mm Hg, dry mucous membranes, and urine
output of 18 mL/hr over the last 2 hours.
Question Stem: Which nursing diagnosis is most appropriate?
Answer Options:
A. Risk for infection
B. Deficient fluid volume
C. Acute confusion
D. Ineffective airway clearance
Correct Answer: B
, Detailed Rationale: Low blood pressure, dry mucous
membranes, and decreased urine output strongly suggest fluid
loss and reduced circulating volume. The diagnosis of deficient
fluid volume best matches the cue cluster and guides
appropriate interventions.
Incorrect Option Analysis:
A: Incorrect because the scenario does not show infection
cues. Misconception: tying all abnormal findings to
infection. Safety risk: wrong priority.
C: Incorrect because confusion is not the primary cue
given. Misconception: overattributing symptoms to
neurologic causes. Safety risk: missed fluid deficit.
D: Incorrect because the patient’s problem is
perfusion/volume, not secretion clearance.
Misconception: confusing respiratory and hemodynamic
problems. Safety risk: ineffective intervention selection.
Nursing Process Linkage: Diagnosis
NCJMM Competencies: Analyze Cues; Prioritize Hypotheses
Clinical Reasoning Focus: Data Interpretation
Difficulty Level: Moderate
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Select the nursing diagnosis that best
fits a fluid-volume deficit cue pattern.
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
Clinical Scenario: A new graduate nurse is caring for a
postoperative patient who was alert and comfortable 30
minutes ago. The patient is now restless, repeatedly removing
,the oxygen cannula, and says, “Something feels wrong.” Heart
rate is 118/min, respiratory rate is 24/min, blood pressure is
98/60 mm Hg.
Question Stem: What is the nurse’s best first action?
Answer Options:
A. Document the changes and reassess after medication pass
B. Assess airway, breathing, circulation, and compare the
findings with baseline
C. Offer water and ask the patient to rest
D. Ask the nursing assistant to stay with the patient while the
nurse continues rounds
Correct Answer: B
Detailed Rationale: The patient is showing early deterioration
cues. The safest first step is immediate assessment of airway,
breathing, circulation, and comparison with baseline data. This
reflects clinical judgment by recognizing and analyzing cues
before acting.
Incorrect Option Analysis:
A: Incorrect because documentation without assessment
delays care. Misconception: “wait and see.” Safety risk:
missed deterioration.
C: Incorrect because hydration is not the priority before
assessing instability. Misconception: assuming anxiety or
thirst. Safety risk: delayed response to hypoxia/shock.
, D: Incorrect because support staff should not be left to
monitor a potentially unstable patient without RN
assessment. Misconception: delegating the problem
instead of assessing it. Safety risk: missed escalation.
Nursing Process Linkage: Assessment
NCJMM Competencies: 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 early instability cues that
require immediate RN assessment.
2) MCQ
Clinical Scenario: A patient receiving furosemide has blood
pressure 86/54 mm Hg, dry mucous membranes, and urine
output of 18 mL/hr over the last 2 hours.
Question Stem: Which nursing diagnosis is most appropriate?
Answer Options:
A. Risk for infection
B. Deficient fluid volume
C. Acute confusion
D. Ineffective airway clearance
Correct Answer: B
, Detailed Rationale: Low blood pressure, dry mucous
membranes, and decreased urine output strongly suggest fluid
loss and reduced circulating volume. The diagnosis of deficient
fluid volume best matches the cue cluster and guides
appropriate interventions.
Incorrect Option Analysis:
A: Incorrect because the scenario does not show infection
cues. Misconception: tying all abnormal findings to
infection. Safety risk: wrong priority.
C: Incorrect because confusion is not the primary cue
given. Misconception: overattributing symptoms to
neurologic causes. Safety risk: missed fluid deficit.
D: Incorrect because the patient’s problem is
perfusion/volume, not secretion clearance.
Misconception: confusing respiratory and hemodynamic
problems. Safety risk: ineffective intervention selection.
Nursing Process Linkage: Diagnosis
NCJMM Competencies: Analyze Cues; Prioritize Hypotheses
Clinical Reasoning Focus: Data Interpretation
Difficulty Level: Moderate
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Select the nursing diagnosis that best
fits a fluid-volume deficit cue pattern.
