TEST BANK FOR HIGH ACUITY NURSING 6TH EDITION KATHLEEN DORMAN WAGNER

Wagner, High Acuity Nursing, 6e Chapter 1 Question 1 Type: MCSA The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate of 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this patient to be which priority for transfer to the intensive care unit (ICU)? 1. Priority 1 2. Priority 2 3. Priority 3 4. Priority 4 Correct Answer: 1 Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment and monitoring not provided outside of the ICU. Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additional interventions. They are typically not evolving an acute event as is the case with this patient. Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their illnesses. Limits are placed on therapeutic interventions and they can be cared for in areas other than the ICU if necessary. Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment are necessary. Global Rationale: Cognitive Level: Analyzing Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-1 Question 2 Type: MCSA