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 74-year-old patient receiving the first dose of a new
,antihypertensive medication says, “I feel dizzy when I stand
up.”
Question Stem:
What is the nurse’s best initial action?
Answer Options:
A. Assist the patient to ambulate to prevent deconditioning.
B. Assess blood pressure and orthostatic vital signs.
C. Notify the provider that the medication must be changed
immediately.
D. Encourage the patient to drink extra water without further
assessment.
Correct Answer:
B
Detailed Rationale:
New dizziness after an antihypertensive is a cue for possible
orthostatic hypotension or medication intolerance. The safest
first step is to assess blood pressure and orthostatic changes
before making decisions or taking further action. This reflects
safe clinical reasoning: recognize the cue, verify the data, then
intervene to prevent falls and other avoidable harm. AHRQ
emphasizes patient safety, assessment-driven care, and
evidence-based action to reduce preventable harm.
Incorrect Option Analysis:
A. Incorrect because ambulation before assessment increases
fall risk.
,C. Incorrect because the provider may need to be notified, but
not before the nurse verifies the patient’s status.
D. Incorrect because fluids may or may not be appropriate;
giving them without assessment can miss hypotension or
another cause.
Nursing Process Linkage: Assessment
Clinical Judgment Competency (NCJMM): Recognize Cues
Clinical Reasoning Focus: Cue Recognition
Difficulty Level: Easy
Bloom’s Level: Apply
NCLEX Client Needs Category: Reduction of Risk Potential
Key Learning Objective: Identify the first nursing action when
medication-related instability is suspected.
2) SATA
Clinical Scenario:
A med-surg unit is revising its fall-prevention protocol after a
spike in patient falls.
Question Stem:
Which actions best reflect evidence-based practice in
developing the new protocol? Select all that apply.
Answer Options:
A. Review current research and clinical guidelines.
B. Combine evidence with clinical expertise and patient
preferences.
, C. Implement the protocol and evaluate fall rates afterward.
D. Use the same steps the unit has always used because they
are familiar.
E. Adopt the protocol only if every nurse already agrees with it.
F. Measure adherence to the bundle after implementation.
Correct Answers:
A, B, C, F
Detailed Rationale:
Evidence-based practice integrates the best available evidence,
clinical expertise, and patient values, then evaluates outcomes
after implementation. Quality improvement also depends on
measuring whether the new process is actually followed and
whether outcomes improve. AHRQ describes EBP as thoughtful
integration of scientific knowledge with clinical expertise and
re-evaluation for improvement, and AHRQ’s safety resources
emphasize consistent bundle use and outcome monitoring.
Incorrect Option Analysis:
D. Incorrect because tradition alone is not evidence.
E. Incorrect because consensus is helpful, but patient safety
decisions should not depend on unanimous staff opinion.
Nursing Process Linkage: Planning, Implementation, Evaluation
Clinical Judgment Competency (NCJMM): Generate Solutions;
Take Action; Evaluate Outcomes
Clinical Reasoning Focus: Intervention Selection
Difficulty Level: Moderate
Bloom’s Level: Analyze
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 74-year-old patient receiving the first dose of a new
,antihypertensive medication says, “I feel dizzy when I stand
up.”
Question Stem:
What is the nurse’s best initial action?
Answer Options:
A. Assist the patient to ambulate to prevent deconditioning.
B. Assess blood pressure and orthostatic vital signs.
C. Notify the provider that the medication must be changed
immediately.
D. Encourage the patient to drink extra water without further
assessment.
Correct Answer:
B
Detailed Rationale:
New dizziness after an antihypertensive is a cue for possible
orthostatic hypotension or medication intolerance. The safest
first step is to assess blood pressure and orthostatic changes
before making decisions or taking further action. This reflects
safe clinical reasoning: recognize the cue, verify the data, then
intervene to prevent falls and other avoidable harm. AHRQ
emphasizes patient safety, assessment-driven care, and
evidence-based action to reduce preventable harm.
Incorrect Option Analysis:
A. Incorrect because ambulation before assessment increases
fall risk.
,C. Incorrect because the provider may need to be notified, but
not before the nurse verifies the patient’s status.
D. Incorrect because fluids may or may not be appropriate;
giving them without assessment can miss hypotension or
another cause.
Nursing Process Linkage: Assessment
Clinical Judgment Competency (NCJMM): Recognize Cues
Clinical Reasoning Focus: Cue Recognition
Difficulty Level: Easy
Bloom’s Level: Apply
NCLEX Client Needs Category: Reduction of Risk Potential
Key Learning Objective: Identify the first nursing action when
medication-related instability is suspected.
2) SATA
Clinical Scenario:
A med-surg unit is revising its fall-prevention protocol after a
spike in patient falls.
Question Stem:
Which actions best reflect evidence-based practice in
developing the new protocol? Select all that apply.
Answer Options:
A. Review current research and clinical guidelines.
B. Combine evidence with clinical expertise and patient
preferences.
, C. Implement the protocol and evaluate fall rates afterward.
D. Use the same steps the unit has always used because they
are familiar.
E. Adopt the protocol only if every nurse already agrees with it.
F. Measure adherence to the bundle after implementation.
Correct Answers:
A, B, C, F
Detailed Rationale:
Evidence-based practice integrates the best available evidence,
clinical expertise, and patient values, then evaluates outcomes
after implementation. Quality improvement also depends on
measuring whether the new process is actually followed and
whether outcomes improve. AHRQ describes EBP as thoughtful
integration of scientific knowledge with clinical expertise and
re-evaluation for improvement, and AHRQ’s safety resources
emphasize consistent bundle use and outcome monitoring.
Incorrect Option Analysis:
D. Incorrect because tradition alone is not evidence.
E. Incorrect because consensus is helpful, but patient safety
decisions should not depend on unanimous staff opinion.
Nursing Process Linkage: Planning, Implementation, Evaluation
Clinical Judgment Competency (NCJMM): Generate Solutions;
Take Action; Evaluate Outcomes
Clinical Reasoning Focus: Intervention Selection
Difficulty Level: Moderate
Bloom’s Level: Analyze
