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 — Core Competencies for Safe and Effective
Healthcare
Clinical Scenario:
A newly admitted patient with heart failure speaks limited
,English. The patient’s adult daughter answers most questions
for the patient and tries to sign the admission forms.
Question Stem:
What is the nurse’s best action to support patient-centered,
safe care?
Answer Options:
A. Ask the daughter to continue interpreting because family
members know the patient best
B. Use a certified interpreter and address questions directly to
the patient
C. Delay the assessment until a bilingual nurse is available
D. Continue the admission using gestures and simple English
Correct Answer:
B
Detailed Rationale:
Using a certified interpreter supports accurate communication,
informed consent, autonomy, and safety. Addressing the
patient directly reinforces person-centered care and helps the
nurse obtain reliable assessment data.
Incorrect Option Analysis:
A: Family interpretation can introduce errors, omissions,
and confidentiality concerns.
C: Delaying assessment can postpone identification of
urgent needs.
, D: Gestures and simple English are not reliable for complex
health assessment or informed decision-making.
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:
Management of Care
Key Learning Objective:
Demonstrate patient-centered communication that promotes
accurate assessment and safe care.
2. MCQ — Clinical Reasoning in the Nursing Process
Clinical Scenario:
A patient with pneumonia reports shortness of breath. The
nurse notes respirations of 28/min, coarse crackles, and oxygen
saturation of 89% on room air.
Question Stem:
Which action is an assessment activity?
, Answer Options:
A. Administer prescribed oxygen
B. Document “impaired gas exchange”
C. Obtain a full respiratory assessment
D. Plan to elevate the head of the bed
Correct Answer:
C
Detailed Rationale:
Assessment involves gathering subjective and objective data. A
full respiratory assessment includes respiratory rate, depth,
breath sounds, oxygen saturation, work of breathing, and
patient report.
Incorrect Option Analysis:
A: This is implementation.
B: This is diagnosis, not assessment.
D: This is planning.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues
Clinical Reasoning Focus:
Cue Recognition
Difficulty Level: Easy
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
1. MCQ — Core Competencies for Safe and Effective
Healthcare
Clinical Scenario:
A newly admitted patient with heart failure speaks limited
,English. The patient’s adult daughter answers most questions
for the patient and tries to sign the admission forms.
Question Stem:
What is the nurse’s best action to support patient-centered,
safe care?
Answer Options:
A. Ask the daughter to continue interpreting because family
members know the patient best
B. Use a certified interpreter and address questions directly to
the patient
C. Delay the assessment until a bilingual nurse is available
D. Continue the admission using gestures and simple English
Correct Answer:
B
Detailed Rationale:
Using a certified interpreter supports accurate communication,
informed consent, autonomy, and safety. Addressing the
patient directly reinforces person-centered care and helps the
nurse obtain reliable assessment data.
Incorrect Option Analysis:
A: Family interpretation can introduce errors, omissions,
and confidentiality concerns.
C: Delaying assessment can postpone identification of
urgent needs.
, D: Gestures and simple English are not reliable for complex
health assessment or informed decision-making.
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:
Management of Care
Key Learning Objective:
Demonstrate patient-centered communication that promotes
accurate assessment and safe care.
2. MCQ — Clinical Reasoning in the Nursing Process
Clinical Scenario:
A patient with pneumonia reports shortness of breath. The
nurse notes respirations of 28/min, coarse crackles, and oxygen
saturation of 89% on room air.
Question Stem:
Which action is an assessment activity?
, Answer Options:
A. Administer prescribed oxygen
B. Document “impaired gas exchange”
C. Obtain a full respiratory assessment
D. Plan to elevate the head of the bed
Correct Answer:
C
Detailed Rationale:
Assessment involves gathering subjective and objective data. A
full respiratory assessment includes respiratory rate, depth,
breath sounds, oxygen saturation, work of breathing, and
patient report.
Incorrect Option Analysis:
A: This is implementation.
B: This is diagnosis, not assessment.
D: This is planning.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues
Clinical Reasoning Focus:
Cue Recognition
Difficulty Level: Easy
