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
Exam Revision Question Bank
Unit 1: Dimensions of Medical-Surgical Nursing
Chapter 1: Medical-Surgical Nursing in the 21st Century
Difficulty: Mixed
,Total Questions: 20
Question 1 (MCQ)
Clinical Scenario
A nurse is caring for a hospitalized patient with heart failure.
During morning assessment, the nurse notices increasing
dyspnea, bilateral crackles, and a 2-kg weight gain over the past
24 hours.
Question Stem
Which action best demonstrates clinical reasoning by the
nurse?
Answer Options
A. Document the findings and continue with scheduled care
B. Notify the provider immediately and anticipate interventions
for fluid overload
C. Reassure the patient that weight fluctuations are expected
D. Wait until the next assessment to determine whether
symptoms worsen
Correct Answer
B. Notify the provider immediately and anticipate
interventions for fluid overload
Detailed Rationale
,The patient demonstrates cues consistent with worsening fluid
volume excess and possible acute decompensated heart failure.
Clinical reasoning requires recognition of abnormal findings,
analysis of their significance, and timely intervention. Prompt
communication and anticipation of treatment may prevent
respiratory compromise.
Incorrect Option Analysis
A: Delays intervention despite significant findings.
C: Minimizes potentially serious symptoms.
D: Waiting may permit further deterioration.
Nursing Process Linkage
Assessment → Implementation
NCJMM Competencies
Recognize Cues
Analyze Cues
Take Action
Clinical Reasoning Focus
Decision-Making
Difficulty
Moderate
Bloom's Level
Analyze
, NCLEX Client Needs
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning to identify and respond to patient
deterioration.
Question 2 (SATA)
Clinical Scenario
A nurse is educating newly hired nurses about QSEN and
healthcare quality competencies.
Question Stem
Which competencies contribute to safe and effective
healthcare? Select all that apply.
Answer Options
A. Patient-centered care
B. Teamwork and collaboration
C. Evidence-based practice
D. Quality improvement
E. Informatics
F. Independent provider practice only
Correct Answers
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
Exam Revision Question Bank
Unit 1: Dimensions of Medical-Surgical Nursing
Chapter 1: Medical-Surgical Nursing in the 21st Century
Difficulty: Mixed
,Total Questions: 20
Question 1 (MCQ)
Clinical Scenario
A nurse is caring for a hospitalized patient with heart failure.
During morning assessment, the nurse notices increasing
dyspnea, bilateral crackles, and a 2-kg weight gain over the past
24 hours.
Question Stem
Which action best demonstrates clinical reasoning by the
nurse?
Answer Options
A. Document the findings and continue with scheduled care
B. Notify the provider immediately and anticipate interventions
for fluid overload
C. Reassure the patient that weight fluctuations are expected
D. Wait until the next assessment to determine whether
symptoms worsen
Correct Answer
B. Notify the provider immediately and anticipate
interventions for fluid overload
Detailed Rationale
,The patient demonstrates cues consistent with worsening fluid
volume excess and possible acute decompensated heart failure.
Clinical reasoning requires recognition of abnormal findings,
analysis of their significance, and timely intervention. Prompt
communication and anticipation of treatment may prevent
respiratory compromise.
Incorrect Option Analysis
A: Delays intervention despite significant findings.
C: Minimizes potentially serious symptoms.
D: Waiting may permit further deterioration.
Nursing Process Linkage
Assessment → Implementation
NCJMM Competencies
Recognize Cues
Analyze Cues
Take Action
Clinical Reasoning Focus
Decision-Making
Difficulty
Moderate
Bloom's Level
Analyze
, NCLEX Client Needs
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning to identify and respond to patient
deterioration.
Question 2 (SATA)
Clinical Scenario
A nurse is educating newly hired nurses about QSEN and
healthcare quality competencies.
Question Stem
Which competencies contribute to safe and effective
healthcare? Select all that apply.
Answer Options
A. Patient-centered care
B. Teamwork and collaboration
C. Evidence-based practice
D. Quality improvement
E. Informatics
F. Independent provider practice only
Correct Answers
