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
Below is an original 20-item exam revision question bank built
from the chapter outline you provided. I used a mixed
distribution because no item counts were specified: 7 MCQ, 4
SATA, 3 NGN case study items, 2 Bow-Tie items, 2 Matrix/Grid
items, 1 Extended Clinical Scenario, and 1 Priority & Delegation
,item. All items are newly written and aligned to clinical
reasoning, patient safety, evidence-based practice, delegation,
ethics, and care coordination.
1) MCQ
Clinical Scenario:
A 68-year-old patient is 4 hours post abdominal surgery. The
nurse notes a respiratory rate of 28/min, oxygen saturation of
89% on 2 L/min via nasal cannula, restlessness, and the patient
saying, “I feel too weak to cough.”
Question Stem:
What is the nurse’s priority first action?
Answer Options:
A. Increase the oxygen flow rate to 4 L/min and reassess in 15
minutes
B. Assess lung sounds, work of breathing, and pain level
immediately
C. Notify the surgeon using SBAR with the current findings
D. Administer the prescribed opioid analgesic before
repositioning
Correct Answer:
B
Detailed Rationale:
The nurse should first assess to confirm the cause of the
deterioration. The patient has cues suggesting possible
,atelectasis, hypoventilation, or postoperative respiratory
compromise. Assessment is the first step in the nursing process
and the safest way to guide next actions.
Incorrect Option Analysis:
A: Increases oxygen without clarifying the cause; this may
delay recognition of a worsening problem.
C: Reporting is appropriate after focused assessment data
are collected.
D: Opioids could worsen respiratory depression if
hypoventilation is the cause.
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: Physiological Adaptation
Key Learning Objective: Identify the priority assessment step
when a postoperative patient shows signs of respiratory
compromise.
2) SATA
, Clinical Scenario:
A new graduate nurse is reviewing safe-practice behaviors for
the med-surg unit.
Question Stem:
Which actions demonstrate core competencies for safe and
effective health care? Select all that apply.
Answer Options:
A. Use two patient identifiers before administering a
medication
B. Discuss a patient’s condition with family members in the
hallway for efficiency
C. Reconcile home medications with admission orders
D. Report a near-miss medication event through the safety
reporting system
E. Skip hand hygiene if gloves will be worn
Correct Answers:
A, C, D
Detailed Rationale:
These actions promote patient safety, continuity, and quality
improvement. Two identifiers reduce wrong-patient errors,
medication reconciliation prevents omissions or duplications,
and reporting near-misses supports systems improvement.
Incorrect Option Analysis:
B: Violates privacy and professionalism; hallway
conversations risk confidentiality breaches.
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
Below is an original 20-item exam revision question bank built
from the chapter outline you provided. I used a mixed
distribution because no item counts were specified: 7 MCQ, 4
SATA, 3 NGN case study items, 2 Bow-Tie items, 2 Matrix/Grid
items, 1 Extended Clinical Scenario, and 1 Priority & Delegation
,item. All items are newly written and aligned to clinical
reasoning, patient safety, evidence-based practice, delegation,
ethics, and care coordination.
1) MCQ
Clinical Scenario:
A 68-year-old patient is 4 hours post abdominal surgery. The
nurse notes a respiratory rate of 28/min, oxygen saturation of
89% on 2 L/min via nasal cannula, restlessness, and the patient
saying, “I feel too weak to cough.”
Question Stem:
What is the nurse’s priority first action?
Answer Options:
A. Increase the oxygen flow rate to 4 L/min and reassess in 15
minutes
B. Assess lung sounds, work of breathing, and pain level
immediately
C. Notify the surgeon using SBAR with the current findings
D. Administer the prescribed opioid analgesic before
repositioning
Correct Answer:
B
Detailed Rationale:
The nurse should first assess to confirm the cause of the
deterioration. The patient has cues suggesting possible
,atelectasis, hypoventilation, or postoperative respiratory
compromise. Assessment is the first step in the nursing process
and the safest way to guide next actions.
Incorrect Option Analysis:
A: Increases oxygen without clarifying the cause; this may
delay recognition of a worsening problem.
C: Reporting is appropriate after focused assessment data
are collected.
D: Opioids could worsen respiratory depression if
hypoventilation is the cause.
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: Physiological Adaptation
Key Learning Objective: Identify the priority assessment step
when a postoperative patient shows signs of respiratory
compromise.
2) SATA
, Clinical Scenario:
A new graduate nurse is reviewing safe-practice behaviors for
the med-surg unit.
Question Stem:
Which actions demonstrate core competencies for safe and
effective health care? Select all that apply.
Answer Options:
A. Use two patient identifiers before administering a
medication
B. Discuss a patient’s condition with family members in the
hallway for efficiency
C. Reconcile home medications with admission orders
D. Report a near-miss medication event through the safety
reporting system
E. Skip hand hygiene if gloves will be worn
Correct Answers:
A, C, D
Detailed Rationale:
These actions promote patient safety, continuity, and quality
improvement. Two identifiers reduce wrong-patient errors,
medication reconciliation prevents omissions or duplications,
and reporting near-misses supports systems improvement.
Incorrect Option Analysis:
B: Violates privacy and professionalism; hallway
conversations risk confidentiality breaches.
