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 shift report on a patient who had abdominal
surgery 6 hours ago. The patient was alert earlier in the shift
,but is now harder to arouse, has shallow respirations, and
reports severe pain.
Question Stem:
Which nursing action should the nurse take first?
Answer Options:
A. Administer the prescribed opioid medication
B. Assess airway, breathing, oxygenation, and full vital signs
C. Document the findings and reassess in 30 minutes
D. Call the surgeon and request discharge be delayed
Correct Answer:
B
Detailed Rationale:
The first step in clinical reasoning is assessment. The nurse
must evaluate airway, breathing, oxygenation, and vital signs
before deciding on treatment. The patient may be experiencing
respiratory depression, hypoxemia, or another postoperative
complication. Immediate assessment supports safe
prioritization and evidence-informed action.
Incorrect Option Analysis:
A: Incorrect because giving an opioid before reassessing
could worsen respiratory depression. Common
misconception: treating pain before confirming safety.
Safety risk: worsening hypoventilation.
, C: Incorrect because delayed reassessment can miss rapid
deterioration. Misconception: that postoperative changes
are always expected. Safety risk: failure to rescue.
D: Incorrect because provider notification is important, but
not before assessing. Misconception: escalation replaces
bedside assessment.
Nursing Process Linkage: 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 the assessment-first response
when postoperative cues suggest possible deterioration.
2) MCQ
Clinical Scenario:
A hospital unit is updating its central line infection prevention
practices after reviewing infection data.
Question Stem:
Which source should the nurse use to guide the new
prevention plan?
Answer Options:
A. A senior nurse’s preferred routine
B. A current evidence-based clinical practice guideline
, C. A staff newsletter from last year
D. A patient discharge handout
Correct Answer:
B
Detailed Rationale:
Evidence-based practice is best supported by current clinical
practice guidelines and high-quality evidence such as
systematic reviews. These sources synthesize research and are
more reliable than tradition or personal preference. Using
guidelines improves consistency, safety, and patient outcomes.
Incorrect Option Analysis:
A: Incorrect; experience can inform practice but cannot
replace evidence. Misconception: “expert opinion is
enough.”
C: Incorrect; a newsletter is not a primary or synthesized
evidence source. Safety risk: outdated practice.
D: Incorrect; patient education materials are not a basis
for clinical policy.
Nursing Process Linkage: Planning
NCJMM Competencies: Prioritize Hypotheses, Generate
Solutions
Clinical Reasoning Focus: Intervention selection
Difficulty: Easy
Bloom’s Level: Understand
NCLEX Client Needs: Management of Care
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 shift report on a patient who had abdominal
surgery 6 hours ago. The patient was alert earlier in the shift
,but is now harder to arouse, has shallow respirations, and
reports severe pain.
Question Stem:
Which nursing action should the nurse take first?
Answer Options:
A. Administer the prescribed opioid medication
B. Assess airway, breathing, oxygenation, and full vital signs
C. Document the findings and reassess in 30 minutes
D. Call the surgeon and request discharge be delayed
Correct Answer:
B
Detailed Rationale:
The first step in clinical reasoning is assessment. The nurse
must evaluate airway, breathing, oxygenation, and vital signs
before deciding on treatment. The patient may be experiencing
respiratory depression, hypoxemia, or another postoperative
complication. Immediate assessment supports safe
prioritization and evidence-informed action.
Incorrect Option Analysis:
A: Incorrect because giving an opioid before reassessing
could worsen respiratory depression. Common
misconception: treating pain before confirming safety.
Safety risk: worsening hypoventilation.
, C: Incorrect because delayed reassessment can miss rapid
deterioration. Misconception: that postoperative changes
are always expected. Safety risk: failure to rescue.
D: Incorrect because provider notification is important, but
not before assessing. Misconception: escalation replaces
bedside assessment.
Nursing Process Linkage: 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 the assessment-first response
when postoperative cues suggest possible deterioration.
2) MCQ
Clinical Scenario:
A hospital unit is updating its central line infection prevention
practices after reviewing infection data.
Question Stem:
Which source should the nurse use to guide the new
prevention plan?
Answer Options:
A. A senior nurse’s preferred routine
B. A current evidence-based clinical practice guideline
, C. A staff newsletter from last year
D. A patient discharge handout
Correct Answer:
B
Detailed Rationale:
Evidence-based practice is best supported by current clinical
practice guidelines and high-quality evidence such as
systematic reviews. These sources synthesize research and are
more reliable than tradition or personal preference. Using
guidelines improves consistency, safety, and patient outcomes.
Incorrect Option Analysis:
A: Incorrect; experience can inform practice but cannot
replace evidence. Misconception: “expert opinion is
enough.”
C: Incorrect; a newsletter is not a primary or synthesized
evidence source. Safety risk: outdated practice.
D: Incorrect; patient education materials are not a basis
for clinical policy.
Nursing Process Linkage: Planning
NCJMM Competencies: Prioritize Hypotheses, Generate
Solutions
Clinical Reasoning Focus: Intervention selection
Difficulty: Easy
Bloom’s Level: Understand
NCLEX Client Needs: Management of Care
