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
Question Number and Type: 1. MCQ
Clinical Scenario:
A nurse is caring for a postoperative adult patient on the
medical-surgical unit. During the first round of assessments, the
patient becomes restless and says, “I feel short of breath.” The
,respiratory rate is 30/min, oxygen saturation is 89% on 2 L/min
via nasal cannula, and the patient’s skin is cool and clammy.
Question Stem:
What is the nurse’s priority first action?
Answer Options:
A. Notify the health care provider immediately
B. Increase the oxygen flow rate to 6 L/min
C. Assess the patient’s airway, breathing, and overall
respiratory status
D. Prepare the patient for transfer to the intensive care unit
Correct Answer:
C. Assess the patient’s airway, breathing, and overall
respiratory status
Detailed Rationale:
The nurse must first assess because clinical reasoning begins
with recognizing cues and verifying the patient’s current status.
Restlessness, dyspnea, tachypnea, low oxygen saturation, and
cool clammy skin suggest possible acute respiratory
compromise or deterioration, but the nurse should not act on
assumptions without completing a focused assessment. The
airway and breathing assessment helps determine whether the
problem is related to hypoventilation, atelectasis, mucus
plugging, pulmonary embolism, pain, or another cause.
Incorrect Option Analysis:
, A. Notify the health care provider immediately — The
provider should be notified after the nurse confirms the
extent of the problem. This option reflects a common
misconception that calling first is always safest. Delayed
assessment can weaken the report and delay the most
appropriate intervention.
B. Increase the oxygen flow rate to 6 L/min — Oxygen
may be indicated, but the nurse should assess first to
determine the source and severity of the problem. Blindly
increasing oxygen without assessment can delay
recognition of a rapidly worsening condition.
D. Prepare the patient for transfer to the intensive care
unit — Transfer may be necessary, but this is premature
before assessing the patient and determining whether
immediate bedside interventions can stabilize the patient.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues
Clinical Reasoning Focus:
Cue Recognition; Data Interpretation
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
, NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Apply the nursing process to recognize early deterioration and
prioritize focused assessment before intervention.
2) SATA
Question Number and Type: 2. Select-All-That-Apply (SATA)
Clinical Scenario:
A newly licensed nurse is preparing to give a handoff report and
document care in the electronic health record. The nurse is also
caring for a patient who asks, “Can you tell my cousin what the
doctor said?”
Question Stem:
Which actions demonstrate professional, ethical, and legally
sound nursing practice? Select all that apply.
Answer Options:
A. Log out of the computer system before leaving the
workstation
B. Share only the minimum necessary information with the
cousin after confirming the patient has authorized disclosure
C. Discuss the patient’s condition in the hallway if no one else
appears to be nearby
D. Use the facility-approved secure messaging system for
communication with the interprofessional team
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
1) MCQ
Question Number and Type: 1. MCQ
Clinical Scenario:
A nurse is caring for a postoperative adult patient on the
medical-surgical unit. During the first round of assessments, the
patient becomes restless and says, “I feel short of breath.” The
,respiratory rate is 30/min, oxygen saturation is 89% on 2 L/min
via nasal cannula, and the patient’s skin is cool and clammy.
Question Stem:
What is the nurse’s priority first action?
Answer Options:
A. Notify the health care provider immediately
B. Increase the oxygen flow rate to 6 L/min
C. Assess the patient’s airway, breathing, and overall
respiratory status
D. Prepare the patient for transfer to the intensive care unit
Correct Answer:
C. Assess the patient’s airway, breathing, and overall
respiratory status
Detailed Rationale:
The nurse must first assess because clinical reasoning begins
with recognizing cues and verifying the patient’s current status.
Restlessness, dyspnea, tachypnea, low oxygen saturation, and
cool clammy skin suggest possible acute respiratory
compromise or deterioration, but the nurse should not act on
assumptions without completing a focused assessment. The
airway and breathing assessment helps determine whether the
problem is related to hypoventilation, atelectasis, mucus
plugging, pulmonary embolism, pain, or another cause.
Incorrect Option Analysis:
, A. Notify the health care provider immediately — The
provider should be notified after the nurse confirms the
extent of the problem. This option reflects a common
misconception that calling first is always safest. Delayed
assessment can weaken the report and delay the most
appropriate intervention.
B. Increase the oxygen flow rate to 6 L/min — Oxygen
may be indicated, but the nurse should assess first to
determine the source and severity of the problem. Blindly
increasing oxygen without assessment can delay
recognition of a rapidly worsening condition.
D. Prepare the patient for transfer to the intensive care
unit — Transfer may be necessary, but this is premature
before assessing the patient and determining whether
immediate bedside interventions can stabilize the patient.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues
Clinical Reasoning Focus:
Cue Recognition; Data Interpretation
Difficulty Level:
Moderate
Bloom’s Cognitive Level:
Apply
, NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Apply the nursing process to recognize early deterioration and
prioritize focused assessment before intervention.
2) SATA
Question Number and Type: 2. Select-All-That-Apply (SATA)
Clinical Scenario:
A newly licensed nurse is preparing to give a handoff report and
document care in the electronic health record. The nurse is also
caring for a patient who asks, “Can you tell my cousin what the
doctor said?”
Question Stem:
Which actions demonstrate professional, ethical, and legally
sound nursing practice? Select all that apply.
Answer Options:
A. Log out of the computer system before leaving the
workstation
B. Share only the minimum necessary information with the
cousin after confirming the patient has authorized disclosure
C. Discuss the patient’s condition in the hallway if no one else
appears to be nearby
D. Use the facility-approved secure messaging system for
communication with the interprofessional team
