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 medical-surgical nurse is admitting a patient after abdominal
surgery. During the initial assessment, the patient says, “I feel
lightheaded and a little nauseated,” and the skin appears pale.
,Question Stem:
What should the nurse do first?
Answer Options:
A. Obtain a full pain history
B. Reassess vital signs and oxygen saturation
C. Administer the prescribed antiemetic
D. Document the patient’s complaint in the chart
Correct Answer:
B. Reassess vital signs and oxygen saturation
Detailed Rationale:
The patient is showing possible cues of acute physiologic
change, including pallor and lightheadedness, which may
indicate hypovolemia, bleeding, vasovagal response, or reduced
oxygenation. The nurse’s first responsibility in clinical reasoning
is to recognize and validate cues through focused assessment
before acting on assumptions. Rechecking vital signs and
oxygen saturation helps determine severity and guides next
steps.
Incorrect Option Analysis:
A. Obtain a full pain history — Pain assessment is
important, but it is not the priority when signs suggest
possible deterioration.
C. Administer the prescribed antiemetic — This may be
appropriate later, but medication should not replace
assessment of unstable cues.
, D. Document the patient’s complaint in the chart —
Documentation is necessary, but not before immediate
reassessment of possible instability.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues, Analyze Cues
Clinical Reasoning Focus:
Cue Recognition
Difficulty Level:
Easy
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Prioritize the first nursing action when a patient demonstrates
cues of possible postoperative deterioration.
2. MCQ
Clinical Scenario:
A unit is implementing an evidence-based falls prevention
bundle for older adult patients.
, Question Stem:
Which nursing action best demonstrates correct use of a care
bundle?
Answer Options:
A. Use only one fall-prevention intervention that seems most
effective
B. Apply the standardized bundle elements to every at-risk
patient
C. Wait until a patient falls before initiating bundle
interventions
D. Use the bundle only when the patient requests extra help
Correct Answer:
B. Apply the standardized bundle elements to every at-risk
patient
Detailed Rationale:
Care bundles are standardized sets of evidence-informed
interventions that are most effective when used consistently
and together. In safety practice, the nurse does not select only
one element or wait for harm to occur. A bundle works because
it reduces variation in care and improves reliability.
Incorrect Option Analysis:
A. Use only one fall-prevention intervention that seems
most effective — This reflects partial implementation and
misses the bundle concept.
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 medical-surgical nurse is admitting a patient after abdominal
surgery. During the initial assessment, the patient says, “I feel
lightheaded and a little nauseated,” and the skin appears pale.
,Question Stem:
What should the nurse do first?
Answer Options:
A. Obtain a full pain history
B. Reassess vital signs and oxygen saturation
C. Administer the prescribed antiemetic
D. Document the patient’s complaint in the chart
Correct Answer:
B. Reassess vital signs and oxygen saturation
Detailed Rationale:
The patient is showing possible cues of acute physiologic
change, including pallor and lightheadedness, which may
indicate hypovolemia, bleeding, vasovagal response, or reduced
oxygenation. The nurse’s first responsibility in clinical reasoning
is to recognize and validate cues through focused assessment
before acting on assumptions. Rechecking vital signs and
oxygen saturation helps determine severity and guides next
steps.
Incorrect Option Analysis:
A. Obtain a full pain history — Pain assessment is
important, but it is not the priority when signs suggest
possible deterioration.
C. Administer the prescribed antiemetic — This may be
appropriate later, but medication should not replace
assessment of unstable cues.
, D. Document the patient’s complaint in the chart —
Documentation is necessary, but not before immediate
reassessment of possible instability.
Nursing Process Linkage:
Assessment
Clinical Judgment Competencies (NCJMM):
Recognize Cues, Analyze Cues
Clinical Reasoning Focus:
Cue Recognition
Difficulty Level:
Easy
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Prioritize the first nursing action when a patient demonstrates
cues of possible postoperative deterioration.
2. MCQ
Clinical Scenario:
A unit is implementing an evidence-based falls prevention
bundle for older adult patients.
, Question Stem:
Which nursing action best demonstrates correct use of a care
bundle?
Answer Options:
A. Use only one fall-prevention intervention that seems most
effective
B. Apply the standardized bundle elements to every at-risk
patient
C. Wait until a patient falls before initiating bundle
interventions
D. Use the bundle only when the patient requests extra help
Correct Answer:
B. Apply the standardized bundle elements to every at-risk
patient
Detailed Rationale:
Care bundles are standardized sets of evidence-informed
interventions that are most effective when used consistently
and together. In safety practice, the nurse does not select only
one element or wait for harm to occur. A bundle works because
it reduces variation in care and improves reliability.
Incorrect Option Analysis:
A. Use only one fall-prevention intervention that seems
most effective — This reflects partial implementation and
misses the bundle concept.
