1
|P a g e
kx kx kx kx kx
, Chapter 1. High-Acuity Nursing kx kx kx
Question 1 T yp kx kx kx
e: MCSA kx
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate o
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
f 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
pa tient to be which priority for transfer to the intensive care unit (ICU)?
kx kx kx kx kx kx kx kx kx kx kx kx kx
1. Priority 1 kx
2. Priority 2 kx
3. Priority 3 kx
4. Priority 4 kx
Correct Answer: 1 kx kx
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other in
kx kx kx bn kx kx kx kx kx kx kx kx kx kx kx kx kx
tensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment and m
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
onitoring not provided outside of the ICU. kx kx kx kx kx kx
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additional inte rve
kx kx kx kx kx kx kx kx kx kx bn kx kx kx kx kx
ntions. They are typically not evolving an acute event as is the case with this patient.
kx kx kx kx bn kx kx kx kx kx kx kx kx kx kx
Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their illnesses
kx kx kx kx kx kx kx kx bn kx kx kx kx kx kx kx
. Limits are placed on therapeutic interventions and they can be cared for in areas other than the ICU
kx kx kx kx bn kx kx kx kx kx kx kx kx kx kx kx bn kx
if necessary.
kx kx
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment
kx kx kx kx bn kx kx kx kx kx kx kx kx bn kx kx
are necessary. kx
Global Rationale: kx
Cognitive Level: Analyzing kx kx
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrate
kx kx kx kx kx bn kx kx kx kx kx kx kx
d Concepts: Nursing Process: Planning Learning Outcome: 1-1
kx kx kx kx kx kx kx
Question 2 Type: MCSA kx kx kx
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care
kx kx kx kx kx kx kx bn bn kx kx kx kx kx kx kx kx k
unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father
x kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx k
may not receive close observation on a busy hospital unit. Which action is indicated by the nurse?
x kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
1. Notify the intensive care unit of an impending transfer.
kx kx kx kx kx kx kx kx
2. Tell the daughter that her father does not meet criteria for placement in the more expensive ICU.
kx kx kx bn kx kx kx kx kx kx kx kx kx kx kx kx
3. Discuss the care that can be provided on the unit with the family member.
kx kx kx kx kx kx kx kx kx kx kx kx kx
2|P a g e
kx kx kx kx kx
,4. Contact the physician. bn kx
Correct Answer: 3 kx kx
Rationale 1: The nurse cannot make this transfer decision independently.
kx kx kx kx kx kx kx kx kx
Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not therapeutic. Bri
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx bn kx
nging up the issue of cost may cause the daughter to offer to pay the difference between the costs of the
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx k
t wo units. This would create a serious ethical dilemma.
x kx kx kx kx kx kx kx kx kx
Rationale 3: The best initial response is to help the daughter understand the level of care and observation t
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
hat will be provided on the MSCU so as to help her understand that her fathers care will be a priority.
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
Rationale 4: The nurse should try to intervene in this situation before involving the physician. Global Rat
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx k
ionale:
x
Cognitive Level: Analyzing kx kx
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrat ed Conce
kx kx kx kx kx bn kx kx kx kx kx kx kx bn
pts: Nursing Process: Implementation Learning Outcome: 1-1
kx kx kx kx kx kx
Question 3 Type: MCSA kx kx kx
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and w
kx kx kx kx kx kx bn kx kx kx kx kx bn kx kx kx kx kx
eaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care envir on
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
ment?
1. Feels comfortable in ever changing situations
kx kx kx kx kx
2. Closely evaluates the pros and cons of each decision for a long period of time before making a decision
kx kx kx kx kx kx kx kx kx kx kx kx bn kx kx kx kx kx
3. Is quiet and introverted
kx kx kx
4. Is excited about all new experiences Correct Answer: 1
kx bn kx kx kx kx bn kx
Rationale 1: The nurse in the intensive care unit must be open to ever-
kx kx kx kx kx kx kx kx kx kx kx kx kx
changing situations. The nurse must be flexible.
kx bn kx kx kx bn kx
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when considering acti
kx kx kx kx kx kx kx kx kx kx kx kx kx kx bn kx kx bn k
ons.
x
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-
kx kx kx kx kx kx kx kx bn kx bn kx kx kx kx kx kx
acuity care unit due to the need for teamwork and interaction.
kx kx kx kx kx kx kx kx kx kx kx
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the m o
kx kx kx kx kx kx kx bn kx kx kx kx kx bn kx kx kx
st important factor for this particular care unit.
kx kx kx kx kx kx kx
Global Rationale: kx
Cognitive Level: Analyzing kx kx
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
kx kx kx kx kx bn kx kx kx kx kx
3|P a g e
kx kx kx kx kx
, Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 kx kx kx kx kx kx kx
Question 4 Type: MCSA kx kx kx
The registered nurse is working as charge nurse on a busy high-
kx kx kx kx kx kx kx kx kx kx kx
acuity care unit. Unexpectedly, a coworker becomes ill and needs to leave. There is a period of time in w
kx kx kx kx kx kx kx kx kx bn kx kx kx kx bn kx kx kx kx
hich the unit is short staffed while the ill coworkers replacement travels in to work. What action by the
kx kx kx kx kx kx kx kx kx kx kx bn kx kx kx kx kx kx kx kx
c harge nurse is indicated?
kx kx kx kx
1. Make no changes until the replacement nurse arrives.
kx kx kx kx kx kx kx
2. Assign the less acute patients to be cared for by the unlicensed assistive personnel.
kx kx kx kx kx kx kx kx kx kx kx kx kx
3. Assign the unlicensed assistive personnel to watch the monitors and call for help if a patient gets into
kx kx kx kx kx kx kx kx kx bn kx kx kx kx kx bn kx
trouble.
kx
4. Contact the house supervisor and ask for a float nurse to be sent to the unit. Correct Answer: 4
bn kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
Rationale 1: The unit is understaffed. Replacement help must be provided. It is inappropriate to wait for
kx kx kx kx kx kx kx kx kx kx kx kx bn kx kx kx k
the replacement nurse.
x kx kx
Rationale 2: The unlicensed assistive personnel are only able to provide care under the direct supervision
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx k
of the nurse.
x kx kx
Rationale 3: Watching monitors is not within the job description of the unlicensed assistive personnel and
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx k
is not appropriate. The manager would be putting both patient safety and the unlicensed assistive person
x kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx k
nel at risk.
x kx kx
Rationale 4: The manager should obtain help until the replacement nurse arrives. Contacting the house s
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
upervisor and asking for a temporary float nurse is the best intervention.
kx kx kx kx kx kx kx bn kx kx kx kx
Global Rationale: kx
Cognitive Level: Analyzing kx kx
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrat
kx kx kx kx kx bn kx kx kx kx kx kx
kx ed Concepts: Nursing Process: Implementation Learning Outcome: 1-2
bn kx kx kx kx kx kx
Question 5 Type: MCSA kx kx kx
A recent nursing school graduate reports having an interview with a magnet hospital. When preparing fo
kx kx kx kx kx kx bn kx kx kx kx kx kx bn kx
r the interview, the graduate nurse researches the concept of magnet status. Which perceptions by the nu
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
r se indicate an adequate understanding?
kx kx kx kx kx
1. Magnet status is an accreditation from the National League for Nurses.
kx kx kx kx kx kx kx kx kx kx
2. Magnet status facilities pay substantial recruitment bonuses.
kx kx kx kx kx bn
3. Magnet status facilities promote the interests of professional nursing.
kx kx kx kx kx kx kx kx
4. Magnet status hospitals must establish nurse-to-patient ratios. Correct Answer: 3
kx kx kx kx kx kx kx kx kx
4|P a g ekx kx kx kx kx
|P a g e
kx kx kx kx kx
, Chapter 1. High-Acuity Nursing kx kx kx
Question 1 T yp kx kx kx
e: MCSA kx
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate o
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
f 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
pa tient to be which priority for transfer to the intensive care unit (ICU)?
kx kx kx kx kx kx kx kx kx kx kx kx kx
1. Priority 1 kx
2. Priority 2 kx
3. Priority 3 kx
4. Priority 4 kx
Correct Answer: 1 kx kx
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other in
kx kx kx bn kx kx kx kx kx kx kx kx kx kx kx kx kx
tensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment and m
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
onitoring not provided outside of the ICU. kx kx kx kx kx kx
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additional inte rve
kx kx kx kx kx kx kx kx kx kx bn kx kx kx kx kx
ntions. They are typically not evolving an acute event as is the case with this patient.
kx kx kx kx bn kx kx kx kx kx kx kx kx kx kx
Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their illnesses
kx kx kx kx kx kx kx kx bn kx kx kx kx kx kx kx
. Limits are placed on therapeutic interventions and they can be cared for in areas other than the ICU
kx kx kx kx bn kx kx kx kx kx kx kx kx kx kx kx bn kx
if necessary.
kx kx
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment
kx kx kx kx bn kx kx kx kx kx kx kx kx bn kx kx
are necessary. kx
Global Rationale: kx
Cognitive Level: Analyzing kx kx
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrate
kx kx kx kx kx bn kx kx kx kx kx kx kx
d Concepts: Nursing Process: Planning Learning Outcome: 1-1
kx kx kx kx kx kx kx
Question 2 Type: MCSA kx kx kx
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care
kx kx kx kx kx kx kx bn bn kx kx kx kx kx kx kx kx k
unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father
x kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx k
may not receive close observation on a busy hospital unit. Which action is indicated by the nurse?
x kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
1. Notify the intensive care unit of an impending transfer.
kx kx kx kx kx kx kx kx
2. Tell the daughter that her father does not meet criteria for placement in the more expensive ICU.
kx kx kx bn kx kx kx kx kx kx kx kx kx kx kx kx
3. Discuss the care that can be provided on the unit with the family member.
kx kx kx kx kx kx kx kx kx kx kx kx kx
2|P a g e
kx kx kx kx kx
,4. Contact the physician. bn kx
Correct Answer: 3 kx kx
Rationale 1: The nurse cannot make this transfer decision independently.
kx kx kx kx kx kx kx kx kx
Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not therapeutic. Bri
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx bn kx
nging up the issue of cost may cause the daughter to offer to pay the difference between the costs of the
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx k
t wo units. This would create a serious ethical dilemma.
x kx kx kx kx kx kx kx kx kx
Rationale 3: The best initial response is to help the daughter understand the level of care and observation t
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
hat will be provided on the MSCU so as to help her understand that her fathers care will be a priority.
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
Rationale 4: The nurse should try to intervene in this situation before involving the physician. Global Rat
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx k
ionale:
x
Cognitive Level: Analyzing kx kx
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrat ed Conce
kx kx kx kx kx bn kx kx kx kx kx kx kx bn
pts: Nursing Process: Implementation Learning Outcome: 1-1
kx kx kx kx kx kx
Question 3 Type: MCSA kx kx kx
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and w
kx kx kx kx kx kx bn kx kx kx kx kx bn kx kx kx kx kx
eaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care envir on
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
ment?
1. Feels comfortable in ever changing situations
kx kx kx kx kx
2. Closely evaluates the pros and cons of each decision for a long period of time before making a decision
kx kx kx kx kx kx kx kx kx kx kx kx bn kx kx kx kx kx
3. Is quiet and introverted
kx kx kx
4. Is excited about all new experiences Correct Answer: 1
kx bn kx kx kx kx bn kx
Rationale 1: The nurse in the intensive care unit must be open to ever-
kx kx kx kx kx kx kx kx kx kx kx kx kx
changing situations. The nurse must be flexible.
kx bn kx kx kx bn kx
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when considering acti
kx kx kx kx kx kx kx kx kx kx kx kx kx kx bn kx kx bn k
ons.
x
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-
kx kx kx kx kx kx kx kx bn kx bn kx kx kx kx kx kx
acuity care unit due to the need for teamwork and interaction.
kx kx kx kx kx kx kx kx kx kx kx
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the m o
kx kx kx kx kx kx kx bn kx kx kx kx kx bn kx kx kx
st important factor for this particular care unit.
kx kx kx kx kx kx kx
Global Rationale: kx
Cognitive Level: Analyzing kx kx
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
kx kx kx kx kx bn kx kx kx kx kx
3|P a g e
kx kx kx kx kx
, Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 kx kx kx kx kx kx kx
Question 4 Type: MCSA kx kx kx
The registered nurse is working as charge nurse on a busy high-
kx kx kx kx kx kx kx kx kx kx kx
acuity care unit. Unexpectedly, a coworker becomes ill and needs to leave. There is a period of time in w
kx kx kx kx kx kx kx kx kx bn kx kx kx kx bn kx kx kx kx
hich the unit is short staffed while the ill coworkers replacement travels in to work. What action by the
kx kx kx kx kx kx kx kx kx kx kx bn kx kx kx kx kx kx kx kx
c harge nurse is indicated?
kx kx kx kx
1. Make no changes until the replacement nurse arrives.
kx kx kx kx kx kx kx
2. Assign the less acute patients to be cared for by the unlicensed assistive personnel.
kx kx kx kx kx kx kx kx kx kx kx kx kx
3. Assign the unlicensed assistive personnel to watch the monitors and call for help if a patient gets into
kx kx kx kx kx kx kx kx kx bn kx kx kx kx kx bn kx
trouble.
kx
4. Contact the house supervisor and ask for a float nurse to be sent to the unit. Correct Answer: 4
bn kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
Rationale 1: The unit is understaffed. Replacement help must be provided. It is inappropriate to wait for
kx kx kx kx kx kx kx kx kx kx kx kx bn kx kx kx k
the replacement nurse.
x kx kx
Rationale 2: The unlicensed assistive personnel are only able to provide care under the direct supervision
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx k
of the nurse.
x kx kx
Rationale 3: Watching monitors is not within the job description of the unlicensed assistive personnel and
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx k
is not appropriate. The manager would be putting both patient safety and the unlicensed assistive person
x kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx k
nel at risk.
x kx kx
Rationale 4: The manager should obtain help until the replacement nurse arrives. Contacting the house s
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
upervisor and asking for a temporary float nurse is the best intervention.
kx kx kx kx kx kx kx bn kx kx kx kx
Global Rationale: kx
Cognitive Level: Analyzing kx kx
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrat
kx kx kx kx kx bn kx kx kx kx kx kx
kx ed Concepts: Nursing Process: Implementation Learning Outcome: 1-2
bn kx kx kx kx kx kx
Question 5 Type: MCSA kx kx kx
A recent nursing school graduate reports having an interview with a magnet hospital. When preparing fo
kx kx kx kx kx kx bn kx kx kx kx kx kx bn kx
r the interview, the graduate nurse researches the concept of magnet status. Which perceptions by the nu
kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx kx
r se indicate an adequate understanding?
kx kx kx kx kx
1. Magnet status is an accreditation from the National League for Nurses.
kx kx kx kx kx kx kx kx kx kx
2. Magnet status facilities pay substantial recruitment bonuses.
kx kx kx kx kx bn
3. Magnet status facilities promote the interests of professional nursing.
kx kx kx kx kx kx kx kx
4. Magnet status hospitals must establish nurse-to-patient ratios. Correct Answer: 3
kx kx kx kx kx kx kx kx kx
4|P a g ekx kx kx kx kx
