Test Bank For High-Acuity Nursing
7th Edition
by Kathleen Wagner, Melanie Hardin-
Pierce, Darlene Welsh & Karen Johnson
All Chapters 1-39 With Rationale s| A+ PASS
1|Page
, 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 (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
The Daughter Of A Patient Who Is Dying Questions The Placement Of Her Father On The
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?
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.
2|Page
,3. Discuss The Care That Can Be Provided On The Unit With The Family Member.
3|Page
, 4. Contact The
Physician.
Correct Answer: 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.
Rationale 4: The NUrse Should Try To Intervene In This Situation Before Involving The Physician.
Global Rationale :
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment Client Need Sub: Management Of Care
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-1
Question 3 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 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 Correct Answer: 1
Rationale 1: The NUrse In The Intensive Care Unit Must Be Open To Ever-Changing Situations. The
NUrse Must Be Flexible.
Rationale 2: The Rapid Changes In The Intensive Care Unit Do Not Allow For Extended Time When
Considering Actions.
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.
Global Rationale :
Cognitive Level: Analyzing
4|Page
7th Edition
by Kathleen Wagner, Melanie Hardin-
Pierce, Darlene Welsh & Karen Johnson
All Chapters 1-39 With Rationale s| A+ PASS
1|Page
, 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 (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
The Daughter Of A Patient Who Is Dying Questions The Placement Of Her Father On The
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?
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.
2|Page
,3. Discuss The Care That Can Be Provided On The Unit With The Family Member.
3|Page
, 4. Contact The
Physician.
Correct Answer: 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.
Rationale 4: The NUrse Should Try To Intervene In This Situation Before Involving The Physician.
Global Rationale :
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment Client Need Sub: Management Of Care
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-1
Question 3 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 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 Correct Answer: 1
Rationale 1: The NUrse In The Intensive Care Unit Must Be Open To Ever-Changing Situations. The
NUrse Must Be Flexible.
Rationale 2: The Rapid Changes In The Intensive Care Unit Do Not Allow For Extended Time When
Considering Actions.
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.
Global Rationale :
Cognitive Level: Analyzing
4|Page
