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Test bank for High Acuity Nursing 7th Edition Wagner Pierce Welsh
Chapter 1. High-Acuity Nursing
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
M
(ICU)?
1. Priority 1
2. Priority 2
EM
3. Priority 3
4. Priority 4
D
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
Ced
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
OT
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
Ne
than the ICU if necessary.
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or
Nst
treatment are necessary.
Global Rationale:
Cognitive Level: Analyzing
OB
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Planning
IaSn
Learning Outcome: 1-1
Question 2
Type: MCSA
The daughter of a patient who is dying questions the placement of her father on the
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medicalsurgical care unit (MSCU). She requests he be placed in the intensive care unit (ICU)
because of concern her father may not receive close observation on a busy hospital unit. Which
action is indicated by the nurse?
s
1. Notify the intensive care unit of an impending transfer.
2. Tell the daughter that her father does not meet criteria for placement in the more expensive
U
ICU.
3. Discuss the care that can be provided on the unit with the family member.
R
4. Contact the physician.
Correct Answer: 3
, l OM oARc PSD|12 26 3 42 3
Rationale 1: The nurse cannot make this transfer decision independently.
Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not
therapeutic. Bringing up the issue of cost may cause the daughter to offer to pay the difference
between the costs of the two units. This would create a serious ethical dilemma.
Rationale 3: The best initial response is to help the daughter understand the level of care and
observation that will be provided on the MSCU so as to help her understand that her fathers care
will be a priority.
M
Rationale 4: The nurse should try to intervene in this situation before involving the physician.
Global Rationale:
Cognitive Level: Analyzing
EM
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
D
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1-1
Question 3
Ced
Type: MCSA
A nurse who is contemplating taking a position in an intensive care unit is reviewing her
strengths and weaknesses. Which characteristics of the nurse will be of the greatest benefit in the
OT
intensive care environment?
1. Feels comfortable in ever changing situations
2. Closely evaluates the pros and cons of each decision for a long period of time before making a
Ne
decision
3. Is quiet and introverted
4. Is excited about all new experiences
Nst
Correct Answer: 1
Rationale 1: The nurse in the intensive care unit must be open to ever-changing situations. The
OB
nurse must be flexible.
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when
considering actions.
IaSn
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-
acuity care unit due to the need for teamwork and interaction.
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is
not the most important factor for this particular care unit.
SkE
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
s
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Assessment
U
Learning Outcome: 1-2
Question 4
Type: MCSA
R
The registered nurse is working as charge nurse on a busy high-acuity care unit. Unexpectedly, a
coworker becomes ill and needs to leave. There is a period of time in which the unit is short
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, l OM oARc PSD|12 26 3 42 3
Test bank for High Acuity Nursing 7th Edition Wagner Pierce Welsh
Chapter 1. High-Acuity Nursing
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
M
(ICU)?
1. Priority 1
2. Priority 2
EM
3. Priority 3
4. Priority 4
D
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
Ced
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
OT
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
Ne
than the ICU if necessary.
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or
Nst
treatment are necessary.
Global Rationale:
Cognitive Level: Analyzing
OB
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Planning
IaSn
Learning Outcome: 1-1
Question 2
Type: MCSA
The daughter of a patient who is dying questions the placement of her father on the
SkE
medicalsurgical care unit (MSCU). She requests he be placed in the intensive care unit (ICU)
because of concern her father may not receive close observation on a busy hospital unit. Which
action is indicated by the nurse?
s
1. Notify the intensive care unit of an impending transfer.
2. Tell the daughter that her father does not meet criteria for placement in the more expensive
U
ICU.
3. Discuss the care that can be provided on the unit with the family member.
R
4. Contact the physician.
Correct Answer: 3
, l OM oARc PSD|12 26 3 42 3
Rationale 1: The nurse cannot make this transfer decision independently.
Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not
therapeutic. Bringing up the issue of cost may cause the daughter to offer to pay the difference
between the costs of the two units. This would create a serious ethical dilemma.
Rationale 3: The best initial response is to help the daughter understand the level of care and
observation that will be provided on the MSCU so as to help her understand that her fathers care
will be a priority.
M
Rationale 4: The nurse should try to intervene in this situation before involving the physician.
Global Rationale:
Cognitive Level: Analyzing
EM
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
D
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1-1
Question 3
Ced
Type: MCSA
A nurse who is contemplating taking a position in an intensive care unit is reviewing her
strengths and weaknesses. Which characteristics of the nurse will be of the greatest benefit in the
OT
intensive care environment?
1. Feels comfortable in ever changing situations
2. Closely evaluates the pros and cons of each decision for a long period of time before making a
Ne
decision
3. Is quiet and introverted
4. Is excited about all new experiences
Nst
Correct Answer: 1
Rationale 1: The nurse in the intensive care unit must be open to ever-changing situations. The
OB
nurse must be flexible.
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when
considering actions.
IaSn
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-
acuity care unit due to the need for teamwork and interaction.
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is
not the most important factor for this particular care unit.
SkE
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
s
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Assessment
U
Learning Outcome: 1-2
Question 4
Type: MCSA
R
The registered nurse is working as charge nurse on a busy high-acuity care unit. Unexpectedly, a
coworker becomes ill and needs to leave. There is a period of time in which the unit is short
