2
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tj tj t j t j t j
, Chapter 1. High-Acuity Nursing tj tj tj
Question1T yp e:MCS tj tj tj tj
A
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate o f
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29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this pa t
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ient to be which priority for transfer to the intensive care unit (ICU)?
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1. Priority 1 tj
2. Priority 2 tj
3. Priority 3 tj
4. Priority 4 tj
Correct Answer: 1 tj tj
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other in te
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nsive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment and m onit
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oring not provided outside of the ICU.
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Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additional inte rve ntions.
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They are typically not evolving an acute event as is the case with this patient.
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Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their illnesses
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. Limits are placed on therapeutic interventions and they can be cared for in areas other than the ICU if
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necessary.
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensivemonitoring or treatment are
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necessary.
Global Rationale: tj
Cognitive Level: Analyzing tj tj
Client Need: Safe Effective Care Environment ClientNeed Sub: Management ofCare Nursing/Integrate d
tj tj tj tj tj tj tj tj tj dx tj tj tj tj
3
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tj tj t j t j t j
,Concepts: Nursing Process: Planning Learning Outcome: 1-1
tj tj tj tj tj tj
Question 2 Type: MCSA tj tj tj
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care uni
tj tj tj dx tj tj tj tj tj tj tj tj tj tj tj tj tj tj
t (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father may
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not receive close observation on a busy hospital unit. Which 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 expensive ICU.
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3. Discussthe care that can be provided on the unit with the family member.
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4
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, 4. Contact the physician. tj tj tj
Correct Answer: 3 tj tj
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 therapeutic. Bri n
tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj bn tj tj
ging up the issue of cost may cause the daughter to offer to pay the difference between the costs of the t w
tj tj tj tj tj tj tj tj tj tj tj tj dx tj tj tj tj tj tj tj t j tj
o 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 observation t ha
tj tj tj tj tj tj tj tj tj tj tj dx tj tj tj tj dx tj tj
t will be provided on the MSCU so as to help her understand that her fathers care will be a priority.
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Rationale 4: The nurse should try to intervene in this situation before involving the physician. Global Rat io
tj tj tj tj tj tj tj tj tj tj tj tj dx tj tj tj tj
nale:
Cognitive Level: Analyzing tj tj
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrat ed Conce pt
tj tj tj tj tj bn tj tj tj tj tj tj tj tj tj
s: Nursing Process: Implementation Learning Outcome: 1-1
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Question 3 Type: MCSA tj tj tj
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and w ea
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knesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care envir on ment
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?
1. Feels comfortable in ever changing situations
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2. Closelyevaluates the pros and cons of each decision for a long period of time before making a decision
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3. Is quiet and introverted
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4. Is excited about allnewexperiences Correct Answer: 1
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Rationale 1: The nurse in the intensive care unit must be open to ever-
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changing situations. The nurse must be flexible.
tj tj tj tj tj tj
Rationale 2: The rapid changes in the intensive care unit do not allowfor extended time when considering acti on
tj tj tj tj tj tj tj tj tj dx tj tj tj tj tj tj dx tj tj
s.
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-
tj tj tj dx tj tj tj tj tj tj tj tj tj tj tj tj tj
acuity care unit due to the need for teamwork and interaction.
tj tj tj tj tj tj tj tj tj dx
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the m o st i
tj tj tj tj tj tj tj tj tj tj tj tj tj tj dx tj tj tj tj
mportant factor for this particular care unit.
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Global Rationale: tj
Cognitive Level: Analyzing tj tj
Client Need: Safe Effective Care Environment ClientNeed Sub: Management of Care
tj tj tj tj tj tj tj tj tj tj tj
5
|P a g e
tj tj t j t j t j
|P a g e
tj tj t j t j t j
, Chapter 1. High-Acuity Nursing tj tj tj
Question1T yp e:MCS tj tj tj tj
A
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate o f
tj tj tj dx tj tj tj tj tj tj tj tj tj tj tj tj tj
29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this pa t
tj tj tj tj tj tj tj tj tj tj tj tj dx tj tj tj
ient to be which priority for transfer to the intensive care unit (ICU)?
tj tj tj tj tj tj tj tj tj tj tj dx
1. Priority 1 tj
2. Priority 2 tj
3. Priority 3 tj
4. Priority 4 tj
Correct Answer: 1 tj tj
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other in te
tj tj tj bn tj tj tj tj tj tj tj tj tj tj tj tj tj tj
nsive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment and m onit
tj tj tj tj tj tj tj tj tj tj tj tj tj tj dx tj tj
oring not provided outside of the ICU.
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Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additional inte rve ntions.
tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj
They are typically not evolving an acute event as is the case with this patient.
tj tj tj tj tj tj tj dx tj tj tj tj tj tj
Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their illnesses
tj tj tj tj tj tj tj tj bn tj tj tj tj tj tj tj
. Limits are placed on therapeutic interventions and they can be cared for in areas other than the ICU if
tj tj tj tj tj tj tj tj tj dx tj tj tj tj tj tj tj tj tj tj
necessary.
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensivemonitoring or treatment are
tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj
necessary.
Global Rationale: tj
Cognitive Level: Analyzing tj tj
Client Need: Safe Effective Care Environment ClientNeed Sub: Management ofCare Nursing/Integrate d
tj tj tj tj tj tj tj tj tj dx tj tj tj tj
3
|P a g e
tj tj t j t j t j
,Concepts: Nursing Process: Planning Learning Outcome: 1-1
tj tj tj tj tj tj
Question 2 Type: MCSA tj tj tj
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care uni
tj tj tj dx tj tj tj tj tj tj tj tj tj tj tj tj tj tj
t (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father may
tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj
not receive close observation on a busy hospital unit. Which action is indicated by the nurse?
tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj
1. Notify the intensive care unit of an impending transfer.
tj tj tj tj tj tj dx tj
2. Tell the daughter that her father does not meet criteria for placement in the more expensive ICU.
tj tj tj tj tj tj tj tj tj tj tj tj dx tj tj tj
3. Discussthe care that can be provided on the unit with the family member.
tj tj tj tj tj tj dx tj tj tj tj tj tj
4
|P a g e
tj tj t j t j t j
, 4. Contact the physician. tj tj tj
Correct Answer: 3 tj tj
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 therapeutic. Bri n
tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj bn tj tj
ging up the issue of cost may cause the daughter to offer to pay the difference between the costs of the t w
tj tj tj tj tj tj tj tj tj tj tj tj dx tj tj tj tj tj tj tj t j tj
o units. This would create a serious ethical dilemma.
tj tj tj tj tj tj tj tj
Rationale 3: The best initial response is to help the daughter understand the level of care and observation t ha
tj tj tj tj tj tj tj tj tj tj tj dx tj tj tj tj dx tj tj
t will be provided on the MSCU so as to help her understand that her fathers care will be a priority.
tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj
Rationale 4: The nurse should try to intervene in this situation before involving the physician. Global Rat io
tj tj tj tj tj tj tj tj tj tj tj tj dx tj tj tj tj
nale:
Cognitive Level: Analyzing tj tj
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrat ed Conce pt
tj tj tj tj tj bn tj tj tj tj tj tj tj tj tj
s: Nursing Process: Implementation Learning Outcome: 1-1
tj tj tj tj tj tj
Question 3 Type: MCSA tj tj tj
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and w ea
tj tj tj tj tj tj tj tj tj tj tj tj tj dx tj tj tj tj tj
knesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care envir on ment
tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj tj
?
1. Feels comfortable in ever changing situations
tj tj dx tj tj
2. Closelyevaluates the pros and cons of each decision for a long period of time before making a decision
tj tj tj tj tj tj tj tj tj tj tj dx tj tj tj tj tj dx
3. Is quiet and introverted
tj tj tj
4. Is excited about allnewexperiences Correct Answer: 1
tj tj dx tj tj tj tj tj
Rationale 1: The nurse in the intensive care unit must be open to ever-
tj tj tj tj tj tj tj tj tj tj tj tj dx
changing situations. The nurse must be flexible.
tj tj tj tj tj tj
Rationale 2: The rapid changes in the intensive care unit do not allowfor extended time when considering acti on
tj tj tj tj tj tj tj tj tj dx tj tj tj tj tj tj dx tj tj
s.
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-
tj tj tj dx tj tj tj tj tj tj tj tj tj tj tj tj tj
acuity care unit due to the need for teamwork and interaction.
tj tj tj tj tj tj tj tj tj dx
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the m o st i
tj tj tj tj tj tj tj tj tj tj tj tj tj tj dx tj tj tj tj
mportant factor for this particular care unit.
tj tj tj tj tj tj
Global Rationale: tj
Cognitive Level: Analyzing tj tj
Client Need: Safe Effective Care Environment ClientNeed Sub: Management of Care
tj tj tj tj tj tj tj tj tj tj tj
5
|P a g e
tj tj t j t j t j
