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 newly admitted 68-year-old patient with heart failure is
receiving IV furosemide. The nurse notes blood pressure 86/54
,mmHg, heart rate 118/min, dry mucous membranes, and urine
output of 15 mL/hr over the last 2 hours.
Question Stem:
Which cue should the nurse prioritize as the most concerning
indicator of a potential problem?
Answer Options:
A. Dry mucous membranes
B. Urine output of 15 mL/hr
C. Heart rate 118/min
D. Blood pressure 86/54 mmHg
Correct Answer:
D. Blood pressure 86/54 mmHg
Detailed Rationale:
Hypotension is the most immediate threat because it suggests
impaired perfusion and possible intravascular volume depletion
from diuresis. This cue can quickly progress to shock, acute
kidney injury, or altered mentation if not addressed. The nurse
must recognize unstable circulation first, then assess the full
picture.
Incorrect Option Analysis:
A: Dry mucous membranes suggest dehydration but are
less urgent than hypotension.
B: Low urine output is concerning and may reflect poor
renal perfusion, but it is a downstream sign.
, C: Tachycardia is a compensatory response, not the
primary cue. It may reflect hypovolemia, pain, or stress.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues, Analyze Cues
Clinical Reasoning Focus: Cue Recognition
Difficulty: Moderate
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify unstable hemodynamic cues
requiring immediate nursing attention.
2) MCQ
Clinical Scenario:
A patient admitted after surgery says, “I do not understand why
I need to use the incentive spirometer every hour.” The patient
has shallow respirations, diminished breath sounds at the
bases, and says pain makes deep breathing uncomfortable.
Question Stem:
Which nursing diagnosis is best supported by these data?
Answer Options:
A. Deficient Knowledge related to postoperative self-care
B. Ineffective Airway Clearance related to retained secretions
C. Anxiety related to hospitalization
D. Risk for Injury related to unfamiliar environment
, Correct Answer:
A. Deficient Knowledge related to postoperative self-care
Detailed Rationale:
The clearest cue is the patient’s statement that they do not
understand the purpose of the incentive spirometer. While
shallow respirations and diminished breath sounds are
important, the question asks for the diagnosis best supported
by the full cue set. Deficient knowledge is directly indicated and
must be addressed to improve recovery and prevent
complications.
Incorrect Option Analysis:
B: Possible, but the problem statement does not show
retained secretions or ineffective coughing.
C: The patient shows discomfort, but anxiety is not clearly
established.
D: No evidence of environmental risk or unsafe behavior is
given.
Nursing Process Linkage: Nursing Diagnosis
NCJMM Competencies: Recognize Cues, Analyze Cues,
Prioritize Hypotheses
Clinical Reasoning Focus: Data Interpretation
Difficulty: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Health Promotion and
Maintenance
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 newly admitted 68-year-old patient with heart failure is
receiving IV furosemide. The nurse notes blood pressure 86/54
,mmHg, heart rate 118/min, dry mucous membranes, and urine
output of 15 mL/hr over the last 2 hours.
Question Stem:
Which cue should the nurse prioritize as the most concerning
indicator of a potential problem?
Answer Options:
A. Dry mucous membranes
B. Urine output of 15 mL/hr
C. Heart rate 118/min
D. Blood pressure 86/54 mmHg
Correct Answer:
D. Blood pressure 86/54 mmHg
Detailed Rationale:
Hypotension is the most immediate threat because it suggests
impaired perfusion and possible intravascular volume depletion
from diuresis. This cue can quickly progress to shock, acute
kidney injury, or altered mentation if not addressed. The nurse
must recognize unstable circulation first, then assess the full
picture.
Incorrect Option Analysis:
A: Dry mucous membranes suggest dehydration but are
less urgent than hypotension.
B: Low urine output is concerning and may reflect poor
renal perfusion, but it is a downstream sign.
, C: Tachycardia is a compensatory response, not the
primary cue. It may reflect hypovolemia, pain, or stress.
Nursing Process Linkage: Assessment
NCJMM Competencies: Recognize Cues, Analyze Cues
Clinical Reasoning Focus: Cue Recognition
Difficulty: Moderate
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
Key Learning Objective: Identify unstable hemodynamic cues
requiring immediate nursing attention.
2) MCQ
Clinical Scenario:
A patient admitted after surgery says, “I do not understand why
I need to use the incentive spirometer every hour.” The patient
has shallow respirations, diminished breath sounds at the
bases, and says pain makes deep breathing uncomfortable.
Question Stem:
Which nursing diagnosis is best supported by these data?
Answer Options:
A. Deficient Knowledge related to postoperative self-care
B. Ineffective Airway Clearance related to retained secretions
C. Anxiety related to hospitalization
D. Risk for Injury related to unfamiliar environment
, Correct Answer:
A. Deficient Knowledge related to postoperative self-care
Detailed Rationale:
The clearest cue is the patient’s statement that they do not
understand the purpose of the incentive spirometer. While
shallow respirations and diminished breath sounds are
important, the question asks for the diagnosis best supported
by the full cue set. Deficient knowledge is directly indicated and
must be addressed to improve recovery and prevent
complications.
Incorrect Option Analysis:
B: Possible, but the problem statement does not show
retained secretions or ineffective coughing.
C: The patient shows discomfort, but anxiety is not clearly
established.
D: No evidence of environmental risk or unsafe behavior is
given.
Nursing Process Linkage: Nursing Diagnosis
NCJMM Competencies: Recognize Cues, Analyze Cues,
Prioritize Hypotheses
Clinical Reasoning Focus: Data Interpretation
Difficulty: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category: Health Promotion and
Maintenance
