Test Bank For High Acuity Nursing, 7th Edition (Wagner), Chapter 1-39 | All Chapters ||Complete A+ Guide

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Test bank for High Acuity Nursing 7th Edition
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Wagner Pierce Welsh -latest m m m m




Chapter 1. High-Acuity Nursing
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mQuestion 1 m



Type: MCSA m



The patient who had surgery yesterday reports his chest feels tight. Assessment reveals
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mrespiratory rate of 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The
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mnurse would consider this patient to be which priority for transfer to the intensive care unit
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m(ICU)?
1. Priority 1 m



2. Priority 2 m



3. Priority 3 m



4. Priority 4 m



Correct Answer: 1 m m



Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation
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mor other intensive treatment may be necessary. Priority 1 patients are acutely ill and need
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mintensive treatment and monitoring not provided outside of the ICU.
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Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially
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mneed additional interventions. They are typically not evolving an acute event as is the case
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mwith this patient.
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Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their
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millnesses. Limits are placed on therapeutic interventions and they can be cared for in areas
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mother than the ICU if necessary.
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Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring
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mor treatment are necessary.
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Global Rationale: m



Cognitive Level: Analyzing m m



Client Need: Safe Effective Care Environment
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mClient Need Sub: Management of Care
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Nursing/Integrated Concepts: Nursing Process: Planning m m m m



mLearning Outcome: 1-1 m m


Question 2 m



mType: MCSA m



The daughter of a patient who is dying questions the placement of her father on the
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mmedicalsurgical care unit (MSCU). She requests he be placed in the intensive care unit (ICU)
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mbecause of concern her father may not receive close observation on a busy hospital unit.
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mWhich action is indicated by the nurse?
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1. Notify the intensive care unit of an impending transfer.
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2. Tell the daughter that her father does not meet criteria for placement in the more
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expensive ICU.
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3. Discuss the care that can be provided on the unit with the family member.
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4. Contact the m



physician.
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Correct Answer: 3
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Rationale 1: The nurse cannot make this transfer decision independently.
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Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not
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mtherapeutic. Bringing up the issue of cost may cause the daughter to offer to pay the
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difference between the costs of the two units. This would create a serious ethical dilemma.
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Rationale 3: The best initial response is to help the daughter understand the level of care and
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mobservation that will be provided on the MSCU so as to help her understand that her fathers
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mcare will be a priority.
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Rationale 4: The nurse should try to intervene in this situation before involving the physician.
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mGlobal Rationale: m



Cognitive Level: Analyzing m m



Client Need: Safe Effective Care Environment
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mClient Need Sub: Management of Care
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Nursing/Integrated Concepts: Nursing Process: Implementation m m m m



mLearning Outcome: 1-1 m m



Question 3 m


mType: MCSA m



A nurse who is contemplating taking a position in an intensive care unit is reviewing her
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mstrengths and weaknesses. Which characteristics of the nurse will be of the greatest benefit in
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mthe intensive care environment?
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1. Feels comfortable in ever changing situations
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2. Closely evaluates the pros and cons of each decision for a long period of time before
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mmaking a decision m m



3. Is quiet and introverted
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4. Is excited about all new
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experiences Correct Answer: 1
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Rationale 1: The nurse in the intensive care unit must be open to ever-changing situations. The
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mnurse must be flexible.
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Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when
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mconsidering actions. m



Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-
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macuity care unit due to the need for teamwork and interaction.
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Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but
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is not the most important factor for this particular care unit.
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Global Rationale: m



Cognitive Level: Analyzing m m



Client Need: Safe Effective Care Environment
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mClient Need Sub: Management of Care
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Nursing/Integrated Concepts: Nursing Process: m m m



Assessment Learning Outcome: 1-2
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Question 4 m



mType: MCSA m



The registered nurse is working as charge nurse on a busy high-acuity care unit. Unexpectedly,
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a coworker becomes ill and needs to leave. There is a period of time in which the unit is
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mshort