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
Question 1 (MCQ)
Clinical Scenario
A nurse is caring for a hospitalized patient with heart failure.
During morning rounds, the nurse notes increasing dyspnea,
crackles in both lung bases, and a 2-kg weight gain in 24 hours.
Question Stem
,Which nursing action best demonstrates the competency of
recognizing cues in clinical reasoning?
Options
A. Administer prescribed diuretics immediately
B. Notify the healthcare provider of possible fluid overload
C. Identify the significance of weight gain and crackles
D. Evaluate the patient's response after treatment
Correct Answer
C. Identify the significance of weight gain and crackles
Detailed Rationale
Recognizing cues is the first step in clinical reasoning. The nurse
must first identify relevant assessment findings indicating
worsening fluid retention before determining interventions.
Weight gain, crackles, and dyspnea are significant cues
suggesting fluid volume excess.
Incorrect Option Analysis
A: Represents intervention rather than cue recognition.
B: Represents action after analysis.
D: Represents evaluation phase.
Nursing Process Linkage
Assessment
NCJMM Competencies
, Recognize Cues
Clinical Reasoning Focus
Cue Recognition
Difficulty
Easy
Bloom's Level
Apply
NCLEX Category
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning principles to identify significant patient
cues.
Question 2 (MCQ)
Clinical Scenario
A nurse receives laboratory results indicating a serum
potassium level of 2.9 mEq/L in a postoperative patient.
Question Stem
Which nursing process step is demonstrated when the nurse
determines that the patient is at risk for cardiac dysrhythmias?
Options
, A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Correct Answer
B. Diagnosis
Detailed Rationale
Diagnosis involves analyzing assessment data and identifying
patient problems or risks. Recognizing that hypokalemia places
the patient at risk for dysrhythmias is diagnostic reasoning.
Incorrect Option Analysis
A: Data collection only.
C: Involves selecting interventions.
D: Involves determining effectiveness.
Nursing Process Linkage
Diagnosis
NCJMM Competencies
Analyze Cues
Prioritize Hypotheses
Clinical Reasoning Focus
Data Interpretation
Difficulty
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
Question 1 (MCQ)
Clinical Scenario
A nurse is caring for a hospitalized patient with heart failure.
During morning rounds, the nurse notes increasing dyspnea,
crackles in both lung bases, and a 2-kg weight gain in 24 hours.
Question Stem
,Which nursing action best demonstrates the competency of
recognizing cues in clinical reasoning?
Options
A. Administer prescribed diuretics immediately
B. Notify the healthcare provider of possible fluid overload
C. Identify the significance of weight gain and crackles
D. Evaluate the patient's response after treatment
Correct Answer
C. Identify the significance of weight gain and crackles
Detailed Rationale
Recognizing cues is the first step in clinical reasoning. The nurse
must first identify relevant assessment findings indicating
worsening fluid retention before determining interventions.
Weight gain, crackles, and dyspnea are significant cues
suggesting fluid volume excess.
Incorrect Option Analysis
A: Represents intervention rather than cue recognition.
B: Represents action after analysis.
D: Represents evaluation phase.
Nursing Process Linkage
Assessment
NCJMM Competencies
, Recognize Cues
Clinical Reasoning Focus
Cue Recognition
Difficulty
Easy
Bloom's Level
Apply
NCLEX Category
Physiological Adaptation
Key Learning Objective
Apply clinical reasoning principles to identify significant patient
cues.
Question 2 (MCQ)
Clinical Scenario
A nurse receives laboratory results indicating a serum
potassium level of 2.9 mEq/L in a postoperative patient.
Question Stem
Which nursing process step is demonstrated when the nurse
determines that the patient is at risk for cardiac dysrhythmias?
Options
, A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Correct Answer
B. Diagnosis
Detailed Rationale
Diagnosis involves analyzing assessment data and identifying
patient problems or risks. Recognizing that hypokalemia places
the patient at risk for dysrhythmias is diagnostic reasoning.
Incorrect Option Analysis
A: Data collection only.
C: Involves selecting interventions.
D: Involves determining effectiveness.
Nursing Process Linkage
Diagnosis
NCJMM Competencies
Analyze Cues
Prioritize Hypotheses
Clinical Reasoning Focus
Data Interpretation
Difficulty
