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 hired registered nurse is reviewing a postoperative
patient's chart and notices that the patient’s heart rate has
increased from 84 to 118 beats/min, blood pressure has
decreased from 128/76 mm Hg to 94/58 mm Hg, and urine
output has dropped to 15 mL/hr over the past 2 hours. The
patient appears restless and reports feeling “dizzy.”
Question Stem
Which action best reflects the first step in clinical reasoning for
this patient?
Answer Options
A. Administer the prescribed antihypertensive medication as
scheduled
B. Recognize these findings as possible signs of deterioration
and immediately reassess the patient
C. Document the findings and recheck the patient in 4 hours
D. Teach the patient to change positions slowly to prevent
dizziness
Correct Answer
B. Recognize these findings as possible signs of deterioration
and immediately reassess the patient
Detailed Rationale
The patient’s tachycardia, hypotension, oliguria, restlessness,
and dizziness suggest acute hemodynamic instability and
possible hypovolemia or shock. Clinical reasoning begins with
,cue recognition: the nurse identifies abnormal trends that
require urgent attention. Immediate reassessment validates
the change in condition and helps guide escalation of care.
Delaying action risks tissue hypoperfusion and organ injury.
Incorrect Option Analysis
A is unsafe because antihypertensive medication could
worsen hypotension. This reflects failure to recognize
deterioration and may cause shock progression.
C is inappropriate because the situation is acute and time-
sensitive; waiting 4 hours could delay lifesaving
intervention.
D is generic patient education and does not address the
unstable condition. It may represent a misconception that
dizziness is a minor positional issue rather than a sign of
compromised perfusion.
Nursing Process Linkage
Assessment
Clinical Judgment Competencies (NCJMM)
Recognize Cues, Analyze Cues
Clinical Reasoning Focus
Cue Recognition
Difficulty Level
Moderate
, Bloom’s Cognitive Level
Analyze
NCLEX Client Needs Category
Reduction of Risk Potential
Key Learning Objective
Identify physiologic cues of patient deterioration and prioritize
immediate reassessment and escalation.
Question 2 — SATA
Clinical Scenario
A nurse educator is teaching a group of new graduates about
evidence-based practice (EBP) and care bundles.
Question Stem
Which statements by the nurses demonstrate correct
understanding of EBP and care bundles? Select all that apply.
Answer Options
A. “EBP combines research evidence, clinical expertise, and
patient preferences.”
B. “Care bundles are optional suggestions that individual nurses
may ignore.”
C. “A care bundle includes a small set of evidence-based
interventions used together.”
D. “EBP replaces clinical judgment when a policy exists.”
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 hired registered nurse is reviewing a postoperative
patient's chart and notices that the patient’s heart rate has
increased from 84 to 118 beats/min, blood pressure has
decreased from 128/76 mm Hg to 94/58 mm Hg, and urine
output has dropped to 15 mL/hr over the past 2 hours. The
patient appears restless and reports feeling “dizzy.”
Question Stem
Which action best reflects the first step in clinical reasoning for
this patient?
Answer Options
A. Administer the prescribed antihypertensive medication as
scheduled
B. Recognize these findings as possible signs of deterioration
and immediately reassess the patient
C. Document the findings and recheck the patient in 4 hours
D. Teach the patient to change positions slowly to prevent
dizziness
Correct Answer
B. Recognize these findings as possible signs of deterioration
and immediately reassess the patient
Detailed Rationale
The patient’s tachycardia, hypotension, oliguria, restlessness,
and dizziness suggest acute hemodynamic instability and
possible hypovolemia or shock. Clinical reasoning begins with
,cue recognition: the nurse identifies abnormal trends that
require urgent attention. Immediate reassessment validates
the change in condition and helps guide escalation of care.
Delaying action risks tissue hypoperfusion and organ injury.
Incorrect Option Analysis
A is unsafe because antihypertensive medication could
worsen hypotension. This reflects failure to recognize
deterioration and may cause shock progression.
C is inappropriate because the situation is acute and time-
sensitive; waiting 4 hours could delay lifesaving
intervention.
D is generic patient education and does not address the
unstable condition. It may represent a misconception that
dizziness is a minor positional issue rather than a sign of
compromised perfusion.
Nursing Process Linkage
Assessment
Clinical Judgment Competencies (NCJMM)
Recognize Cues, Analyze Cues
Clinical Reasoning Focus
Cue Recognition
Difficulty Level
Moderate
, Bloom’s Cognitive Level
Analyze
NCLEX Client Needs Category
Reduction of Risk Potential
Key Learning Objective
Identify physiologic cues of patient deterioration and prioritize
immediate reassessment and escalation.
Question 2 — SATA
Clinical Scenario
A nurse educator is teaching a group of new graduates about
evidence-based practice (EBP) and care bundles.
Question Stem
Which statements by the nurses demonstrate correct
understanding of EBP and care bundles? Select all that apply.
Answer Options
A. “EBP combines research evidence, clinical expertise, and
patient preferences.”
B. “Care bundles are optional suggestions that individual nurses
may ignore.”
C. “A care bundle includes a small set of evidence-based
interventions used together.”
D. “EBP replaces clinical judgment when a policy exists.”
