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
1. Question Number and Type: MCQ
Clinical Scenario:
A newly licensed nurse is reviewing a patient’s plan of care for a
client admitted with pneumonia. The nurse notices the
,respiratory assessment was completed, but no nursing
diagnosis or outcome goals were documented yet.
Question Stem:
Which action best reflects the next step in the nursing process?
Answer Options:
A. Implement oxygen therapy immediately
B. Reassess the client’s oxygen saturation
C. Formulate a nursing diagnosis based on assessment data
D. Evaluate whether the pneumonia is improving
Correct Answer:
C. Formulate a nursing diagnosis based on assessment data
Detailed Rationale:
The nursing process is sequential and begins with assessment.
Once assessment data are collected, the nurse analyzes the
cues and identifies a nursing diagnosis. This diagnosis guides
planning and intervention. In this scenario, the client has
already been assessed, so the next step is diagnosis. Clinical
reasoning requires the nurse to move from raw data to
interpretation before planning care.
Incorrect Option Analysis:
A. Implement oxygen therapy immediately — Incorrect
because interventions should be based on analysis and
planning unless there is an urgent emergency. This reflects
action without sufficient reasoning. Safety risk: premature
intervention without confirming need.
, B. Reassess the client’s oxygen saturation — Incorrect
because the scenario indicates assessment was already
completed. Reassessment may be appropriate if data are
incomplete, but not as the next step here.
D. Evaluate whether the pneumonia is improving —
Incorrect because evaluation occurs after interventions
have been implemented. This is a premature step.
Nursing Process Linkage:
Diagnosis
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues
Clinical Reasoning Focus:
Decision-Making
Difficulty Level:
Easy
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Management of Care
Key Learning Objective:
Identify the correct sequence of the nursing process in clinical
reasoning.
2) MCQ
, 2. Question Number and Type: MCQ
Clinical Scenario:
A nurse is reviewing evidence-based practice findings before
revising a unit protocol for preventing central line infections.
Question Stem:
Which statement best describes evidence-based practice?
Answer Options:
A. Using only expert opinion to guide care
B. Applying the best available research with clinical expertise
and patient preferences
C. Following physician orders exactly as written
D. Selecting the intervention that is easiest to implement
Correct Answer:
B. Applying the best available research with clinical expertise
and patient preferences
Detailed Rationale:
Evidence-based practice integrates high-quality research
evidence, clinical expertise, and patient values/preferences. It is
a core competency for safe, effective care and supports quality
improvement, safety, and standardized care bundles.
Incorrect Option Analysis:
A. Using only expert opinion to guide care — Incorrect
because expert opinion alone is not sufficient evidence.
Safety concern: care may not reflect best outcomes.
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
1) MCQ
1. Question Number and Type: MCQ
Clinical Scenario:
A newly licensed nurse is reviewing a patient’s plan of care for a
client admitted with pneumonia. The nurse notices the
,respiratory assessment was completed, but no nursing
diagnosis or outcome goals were documented yet.
Question Stem:
Which action best reflects the next step in the nursing process?
Answer Options:
A. Implement oxygen therapy immediately
B. Reassess the client’s oxygen saturation
C. Formulate a nursing diagnosis based on assessment data
D. Evaluate whether the pneumonia is improving
Correct Answer:
C. Formulate a nursing diagnosis based on assessment data
Detailed Rationale:
The nursing process is sequential and begins with assessment.
Once assessment data are collected, the nurse analyzes the
cues and identifies a nursing diagnosis. This diagnosis guides
planning and intervention. In this scenario, the client has
already been assessed, so the next step is diagnosis. Clinical
reasoning requires the nurse to move from raw data to
interpretation before planning care.
Incorrect Option Analysis:
A. Implement oxygen therapy immediately — Incorrect
because interventions should be based on analysis and
planning unless there is an urgent emergency. This reflects
action without sufficient reasoning. Safety risk: premature
intervention without confirming need.
, B. Reassess the client’s oxygen saturation — Incorrect
because the scenario indicates assessment was already
completed. Reassessment may be appropriate if data are
incomplete, but not as the next step here.
D. Evaluate whether the pneumonia is improving —
Incorrect because evaluation occurs after interventions
have been implemented. This is a premature step.
Nursing Process Linkage:
Diagnosis
Clinical Judgment Competencies (NCJMM):
Recognize Cues; Analyze Cues
Clinical Reasoning Focus:
Decision-Making
Difficulty Level:
Easy
Bloom’s Cognitive Level:
Apply
NCLEX Client Needs Category:
Management of Care
Key Learning Objective:
Identify the correct sequence of the nursing process in clinical
reasoning.
2) MCQ
, 2. Question Number and Type: MCQ
Clinical Scenario:
A nurse is reviewing evidence-based practice findings before
revising a unit protocol for preventing central line infections.
Question Stem:
Which statement best describes evidence-based practice?
Answer Options:
A. Using only expert opinion to guide care
B. Applying the best available research with clinical expertise
and patient preferences
C. Following physician orders exactly as written
D. Selecting the intervention that is easiest to implement
Correct Answer:
B. Applying the best available research with clinical expertise
and patient preferences
Detailed Rationale:
Evidence-based practice integrates high-quality research
evidence, clinical expertise, and patient values/preferences. It is
a core competency for safe, effective care and supports quality
improvement, safety, and standardized care bundles.
Incorrect Option Analysis:
A. Using only expert opinion to guide care — Incorrect
because expert opinion alone is not sufficient evidence.
Safety concern: care may not reflect best outcomes.
