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:
An adult patient on a medical-surgical unit reports feeling
“lightheaded” when sitting up after surgery. The nurse notes
,the patient’s blood pressure has decreased from 138/84 mm Hg
earlier in the shift to 102/60 mm Hg, and the heart rate is now
110/min.
Question Stem:
What is the nurse’s best first action?
Answer Options:
A. Reassess the patient and compare the current findings with
baseline data.
B. Document the findings as expected after surgery.
C. Encourage the patient to ambulate to improve circulation.
D. Administer the next scheduled opioid for comfort.
Correct Answer:
A
Detailed Rationale:
The nurse should first reassess and interpret the change in cues
before taking further action. A drop in blood pressure with
tachycardia and dizziness may indicate fluid volume deficit,
bleeding, or orthostatic intolerance. Clinical reasoning begins
with accurate cue recognition and validation of the patient’s
current status.
Incorrect Option Analysis:
B: Incorrect because these findings are not automatically
expected and may signal deterioration. This reflects the
misconception that postoperative changes are always
, benign. It could delay recognition of hypovolemia or
hemorrhage.
C: Incorrect because ambulation before reassessment
could increase fall risk and worsen hypotension.
D: Incorrect because opioid administration may further
lower blood pressure and mask worsening symptoms.
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 early cues of physiologic instability and prioritize
reassessment before intervention.
2) SATA
, Question Number and Type: 2 — SATA
Clinical Scenario:
A nurse orienting to the unit asks which actions best reflect safe
and effective medical-surgical nursing practice.
Question Stem:
Which actions demonstrate core competencies for safe and
effective healthcare? Select all that apply.
Answer Options:
A. Using two patient identifiers before medication
administration
B. Involving the patient in setting daily care goals
C. Checking current evidence-based guidelines before changing
a care plan
D. Discussing a patient’s situation in the hallway because names
are not used
E. Using a standardized handoff process during shift report
Correct Answer:
A, B, C, E
Detailed Rationale:
Safe and effective care includes patient identification, patient-
centered goal setting, evidence-based practice, and
standardized communication. These actions reduce harm,
improve continuity, and support quality care.
Incorrect Option Analysis:
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:
An adult patient on a medical-surgical unit reports feeling
“lightheaded” when sitting up after surgery. The nurse notes
,the patient’s blood pressure has decreased from 138/84 mm Hg
earlier in the shift to 102/60 mm Hg, and the heart rate is now
110/min.
Question Stem:
What is the nurse’s best first action?
Answer Options:
A. Reassess the patient and compare the current findings with
baseline data.
B. Document the findings as expected after surgery.
C. Encourage the patient to ambulate to improve circulation.
D. Administer the next scheduled opioid for comfort.
Correct Answer:
A
Detailed Rationale:
The nurse should first reassess and interpret the change in cues
before taking further action. A drop in blood pressure with
tachycardia and dizziness may indicate fluid volume deficit,
bleeding, or orthostatic intolerance. Clinical reasoning begins
with accurate cue recognition and validation of the patient’s
current status.
Incorrect Option Analysis:
B: Incorrect because these findings are not automatically
expected and may signal deterioration. This reflects the
misconception that postoperative changes are always
, benign. It could delay recognition of hypovolemia or
hemorrhage.
C: Incorrect because ambulation before reassessment
could increase fall risk and worsen hypotension.
D: Incorrect because opioid administration may further
lower blood pressure and mask worsening symptoms.
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 early cues of physiologic instability and prioritize
reassessment before intervention.
2) SATA
, Question Number and Type: 2 — SATA
Clinical Scenario:
A nurse orienting to the unit asks which actions best reflect safe
and effective medical-surgical nursing practice.
Question Stem:
Which actions demonstrate core competencies for safe and
effective healthcare? Select all that apply.
Answer Options:
A. Using two patient identifiers before medication
administration
B. Involving the patient in setting daily care goals
C. Checking current evidence-based guidelines before changing
a care plan
D. Discussing a patient’s situation in the hallway because names
are not used
E. Using a standardized handoff process during shift report
Correct Answer:
A, B, C, E
Detailed Rationale:
Safe and effective care includes patient identification, patient-
centered goal setting, evidence-based practice, and
standardized communication. These actions reduce harm,
improve continuity, and support quality care.
Incorrect Option Analysis:
