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
Question 1 – MCQ
Clinical Scenario: A newly licensed nurse is caring for a
postoperative patient whose oxygen saturation has decreased
from 97% to 89% over the past 15 minutes.
,Question: Which action best demonstrates the competency of
clinical judgment?
1. Document the oxygen saturation and continue
monitoring.
1. Notify
1. Assess respiratory rate
1. Administer a prescribed
Correct Answer: 3
Rationale: Clinical judgment begins with recognizing and
analyzing cues. A drop in oxygen saturation is a significant cue,
but the nurse should gather additional assessment data
(respiratory rate, breath sounds, mental status) to determine
the most appropriate intervention.
Incorrect Option Analysis:
1: Delays assessment and intervention; may allow
deterioration.
2: Premature escalation without sufficient data.
4: Opioids may worsen respiratory depression.
,Nursing Process: Assessment
NCJMM: Recognize Cues, Analyze Cues
Clinical Reasoning Focus: Cue Recognition
Difficulty: Moderate
Bloom's Level: Analyze
NCLEX Category: Physiological Adaptation
Question 2 – SATA
Clinical Scenario: A nurse is implementing evidence-based
practice (EBP) on a medical-surgical unit.
Question: Which actions are consistent with EBP? Select all that
apply.
A. Using current clinical guidelines
B. Considering patient preferences
C. Relying solely on personal experience
D. Reviewing recent research findings
E. Collaborating with the interprofessional team
Correct Answers: A, B, D, E
Rationale: EBP integrates best current evidence, clinical
expertise, patient preferences, and collaboration with the
healthcare team.
Incorrect Option Analysis:
, C: Personal experience alone does not constitute EBP and
may perpetuate outdated practices.
Nursing Process: Planning
NCJMM: Generate Solutions
Clinical Reasoning Focus: Decision-Making
Difficulty: Easy
Bloom's Level: Understand
NCLEX Category: Management of Care
Question 3 – MCQ
Clinical Scenario: A nurse is collecting data from a patient
admitted with heart failure.
Question: Which activity is part of the assessment phase of the
nursing process?
1. Identifying impaired gas exchange
1. Measuring
1. Developing discharge goals
1. Determ
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
Question 1 – MCQ
Clinical Scenario: A newly licensed nurse is caring for a
postoperative patient whose oxygen saturation has decreased
from 97% to 89% over the past 15 minutes.
,Question: Which action best demonstrates the competency of
clinical judgment?
1. Document the oxygen saturation and continue
monitoring.
1. Notify
1. Assess respiratory rate
1. Administer a prescribed
Correct Answer: 3
Rationale: Clinical judgment begins with recognizing and
analyzing cues. A drop in oxygen saturation is a significant cue,
but the nurse should gather additional assessment data
(respiratory rate, breath sounds, mental status) to determine
the most appropriate intervention.
Incorrect Option Analysis:
1: Delays assessment and intervention; may allow
deterioration.
2: Premature escalation without sufficient data.
4: Opioids may worsen respiratory depression.
,Nursing Process: Assessment
NCJMM: Recognize Cues, Analyze Cues
Clinical Reasoning Focus: Cue Recognition
Difficulty: Moderate
Bloom's Level: Analyze
NCLEX Category: Physiological Adaptation
Question 2 – SATA
Clinical Scenario: A nurse is implementing evidence-based
practice (EBP) on a medical-surgical unit.
Question: Which actions are consistent with EBP? Select all that
apply.
A. Using current clinical guidelines
B. Considering patient preferences
C. Relying solely on personal experience
D. Reviewing recent research findings
E. Collaborating with the interprofessional team
Correct Answers: A, B, D, E
Rationale: EBP integrates best current evidence, clinical
expertise, patient preferences, and collaboration with the
healthcare team.
Incorrect Option Analysis:
, C: Personal experience alone does not constitute EBP and
may perpetuate outdated practices.
Nursing Process: Planning
NCJMM: Generate Solutions
Clinical Reasoning Focus: Decision-Making
Difficulty: Easy
Bloom's Level: Understand
NCLEX Category: Management of Care
Question 3 – MCQ
Clinical Scenario: A nurse is collecting data from a patient
admitted with heart failure.
Question: Which activity is part of the assessment phase of the
nursing process?
1. Identifying impaired gas exchange
1. Measuring
1. Developing discharge goals
1. Determ
