Test Bank For High-Acuity Nursing 7th Edition
All Chapters
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 - ANSWER>>ANSWER: 1
Explanation: 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.
2. Priority 2 refers to patients who need intensive monitoring and may potentially need
additional interventions. They are typically not evolving an acute event as is the case with this
patient.
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.
4. Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment
are necessary.
The daughter of a patient who is dying questions the placement of her father on the medical-
surgical 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?
,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
ICU.
3. Discuss the care that can be provided on the unit with the family member.
4. Contact the physician. - ANSWER>>ANSWER: 3
Explanation: 1. The nurse cannot make this transfer decision independently.
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.
3. The best initial response is to help the daughter understand the level of care and observation
that will be provided on the MSCU to help her understand that her father's care will be a
priority.
4. The nurse should try to intervene in this situation before involving the physician.
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 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 decision
3. Is quiet and introverted
4. Is excited about all new experiences - ANSWER>>ANSWER: 1
Explanation: 1. The nurse in the intensive care unit must be open to ever-changing situations.
The nurse must be flexible.
2. The rapid changes in the intensive care unit do not allow for extended time when considering
actions.
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.
, 4. Excitement about all experiences is a beneficial characteristic in healthcare but is not the
most important factor for this care unit.
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
staffed while the ill coworker's replacement travels in to work. What action by the charge nurse
is indicated?
1. Make no changes until the replacement nurse arrives.
2. Assign the less acute patients to be cared for by the unlicensed assistive personnel.
3. Assign the unlicensed assistive personnel to watch the monitors and call for help if a patient
"gets into trouble."
4. Contact the house supervisor and ask for a float nurse to be sent to the unit. -
ANSWER>>ANSWER: 4
Explanation: 1. The unit is understaffed. Replacement help must be provided. It is inappropriate
to wait for the replacement nurse.
2. The unlicensed assistive personnel are only able to provide care under the direct supervision
of the nurse.
3. Watching monitors is not within the job description of the unlicensed assistive personnel and
is not appropriate. The manager would be putting both patient safety and the unlicensed
assistive personnel at risk.
4. The manager should obtain help until the replacement nurse arrives. Contacting the house
supervisor and asking for a temporary float nurse is the best intervention.
A recent nursing school graduate reports having an interview with a magnet hospital. When
preparing for the interview, the graduate nurse researches the concept of magnet status.
Which perceptions by the nurse indicate an adequate understanding?
1. Magnet status is an accreditation from the National League for Nurses.
All Chapters
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 - ANSWER>>ANSWER: 1
Explanation: 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.
2. Priority 2 refers to patients who need intensive monitoring and may potentially need
additional interventions. They are typically not evolving an acute event as is the case with this
patient.
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.
4. Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment
are necessary.
The daughter of a patient who is dying questions the placement of her father on the medical-
surgical 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?
,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
ICU.
3. Discuss the care that can be provided on the unit with the family member.
4. Contact the physician. - ANSWER>>ANSWER: 3
Explanation: 1. The nurse cannot make this transfer decision independently.
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.
3. The best initial response is to help the daughter understand the level of care and observation
that will be provided on the MSCU to help her understand that her father's care will be a
priority.
4. The nurse should try to intervene in this situation before involving the physician.
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 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 decision
3. Is quiet and introverted
4. Is excited about all new experiences - ANSWER>>ANSWER: 1
Explanation: 1. The nurse in the intensive care unit must be open to ever-changing situations.
The nurse must be flexible.
2. The rapid changes in the intensive care unit do not allow for extended time when considering
actions.
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.
, 4. Excitement about all experiences is a beneficial characteristic in healthcare but is not the
most important factor for this care unit.
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
staffed while the ill coworker's replacement travels in to work. What action by the charge nurse
is indicated?
1. Make no changes until the replacement nurse arrives.
2. Assign the less acute patients to be cared for by the unlicensed assistive personnel.
3. Assign the unlicensed assistive personnel to watch the monitors and call for help if a patient
"gets into trouble."
4. Contact the house supervisor and ask for a float nurse to be sent to the unit. -
ANSWER>>ANSWER: 4
Explanation: 1. The unit is understaffed. Replacement help must be provided. It is inappropriate
to wait for the replacement nurse.
2. The unlicensed assistive personnel are only able to provide care under the direct supervision
of the nurse.
3. Watching monitors is not within the job description of the unlicensed assistive personnel and
is not appropriate. The manager would be putting both patient safety and the unlicensed
assistive personnel at risk.
4. The manager should obtain help until the replacement nurse arrives. Contacting the house
supervisor and asking for a temporary float nurse is the best intervention.
A recent nursing school graduate reports having an interview with a magnet hospital. When
preparing for the interview, the graduate nurse researches the concept of magnet status.
Which perceptions by the nurse indicate an adequate understanding?
1. Magnet status is an accreditation from the National League for Nurses.
