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 receives report on a postoperative
patient whose blood pressure dropped from 128/78 mm Hg to
94/56 mm Hg, heart rate is 118/min, and the patient says, “I
feel dizzy when I sit up.”
Stem: What is the nurse’s best next action?
Answer options:
A. Document the findings and reassess in 30 minutes
B. Perform a focused assessment and recheck vital signs
immediately
C. Administer the prescribed pain medication
D. Encourage the patient to ambulate to improve circulation
Correct answer: B
Detailed rationale:
The nurse is recognizing cues that may indicate hypovolemia,
bleeding, or hemodynamic instability. The best first action is a
focused assessment with repeat vital signs to confirm the
change and identify the cause. This reflects the assessment
phase of the nursing process and supports safe escalation of
care if needed.
Incorrect option analysis:
A: Delaying reassessment may miss deterioration. This
reflects the misconception that charting alone is sufficient.
Safety risk: delayed intervention in possible shock.
, C: Pain medication could worsen hypotension and does
not address the cause of the problem. Misconception:
treating a symptom before evaluating instability.
D: Ambulation is unsafe with symptomatic hypotension
and dizziness. Misconception: movement always improves
circulation. Safety risk: fall or syncope.
Nursing process link: Assessment
NCJMM competencies: Recognize Cues, Analyze Cues
Clinical reasoning focus: Cue Recognition
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Physiological Adaptation
Key learning objective: Identify abnormal postoperative cues
and prioritize immediate assessment for potential
deterioration.
2) MCQ
Clinical scenario: A nurse is helping the unit reduce central line
infections using an evidence-informed approach.
Stem: Which statement best reflects evidence-based practice?
Answer options:
A. “I will use the same dressing change method because it has
always worked here.”
B. “I will combine current best evidence, clinical expertise, and
patient preferences.”
, C. “I will follow only the newest research article I found online.”
D. “I will use the method requested by the most senior staff
member.”
Correct answer: B
Detailed rationale:
Evidence-based practice integrates the best available research,
clinical expertise, and patient values/preferences. That is the
core of contemporary safe practice and aligns with chapter
concepts on EBP guidelines and care bundles.
Incorrect option analysis:
A: Tradition alone is not evidence-based. Misconception:
long-standing practice automatically equals best practice.
Safety risk: outdated care.
C: One article alone may not be enough evidence.
Misconception: newer always means better. Safety risk:
adopting weak or biased evidence.
D: Seniority does not replace evidence. Misconception:
authority equals correctness. Safety risk: practice based on
opinion rather than evidence.
Nursing process link: Planning
NCJMM competencies: Prioritize Hypotheses, Generate
Solutions
Clinical reasoning focus: Decision-Making
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 receives report on a postoperative
patient whose blood pressure dropped from 128/78 mm Hg to
94/56 mm Hg, heart rate is 118/min, and the patient says, “I
feel dizzy when I sit up.”
Stem: What is the nurse’s best next action?
Answer options:
A. Document the findings and reassess in 30 minutes
B. Perform a focused assessment and recheck vital signs
immediately
C. Administer the prescribed pain medication
D. Encourage the patient to ambulate to improve circulation
Correct answer: B
Detailed rationale:
The nurse is recognizing cues that may indicate hypovolemia,
bleeding, or hemodynamic instability. The best first action is a
focused assessment with repeat vital signs to confirm the
change and identify the cause. This reflects the assessment
phase of the nursing process and supports safe escalation of
care if needed.
Incorrect option analysis:
A: Delaying reassessment may miss deterioration. This
reflects the misconception that charting alone is sufficient.
Safety risk: delayed intervention in possible shock.
, C: Pain medication could worsen hypotension and does
not address the cause of the problem. Misconception:
treating a symptom before evaluating instability.
D: Ambulation is unsafe with symptomatic hypotension
and dizziness. Misconception: movement always improves
circulation. Safety risk: fall or syncope.
Nursing process link: Assessment
NCJMM competencies: Recognize Cues, Analyze Cues
Clinical reasoning focus: Cue Recognition
Difficulty: Moderate
Bloom’s level: Apply
NCLEX client needs: Physiological Adaptation
Key learning objective: Identify abnormal postoperative cues
and prioritize immediate assessment for potential
deterioration.
2) MCQ
Clinical scenario: A nurse is helping the unit reduce central line
infections using an evidence-informed approach.
Stem: Which statement best reflects evidence-based practice?
Answer options:
A. “I will use the same dressing change method because it has
always worked here.”
B. “I will combine current best evidence, clinical expertise, and
patient preferences.”
, C. “I will follow only the newest research article I found online.”
D. “I will use the method requested by the most senior staff
member.”
Correct answer: B
Detailed rationale:
Evidence-based practice integrates the best available research,
clinical expertise, and patient values/preferences. That is the
core of contemporary safe practice and aligns with chapter
concepts on EBP guidelines and care bundles.
Incorrect option analysis:
A: Tradition alone is not evidence-based. Misconception:
long-standing practice automatically equals best practice.
Safety risk: outdated care.
C: One article alone may not be enough evidence.
Misconception: newer always means better. Safety risk:
adopting weak or biased evidence.
D: Seniority does not replace evidence. Misconception:
authority equals correctness. Safety risk: practice based on
opinion rather than evidence.
Nursing process link: Planning
NCJMM competencies: Prioritize Hypotheses, Generate
Solutions
Clinical reasoning focus: Decision-Making
Difficulty: Easy
Bloom’s level: Understand
