Test Bank For High-Acuity Nursing 7th Edition By Kathleen Dorman Wagner RN, MSN, CS; Melanie Hardin-Pierce; Darlene Welsh; Karen Johnson RN, PhD, CCR 9780134459295 Chapter 1-39 Complete Guide .

Test Bank for High-Acuity Nursing 7th
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ix Edition
by Kathleen Wagner, Melanie Hardin-
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ix Pierce, Darlene Welsh & Karen Johnson
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All Chapters 1-39 With Rationales| A+ PASS
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1|P a g e
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, Chapter 1. High-Acuity Nursing ix ix ix




Question 1 ix




ix Type:

MCSA
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The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate of
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29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this
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patient to be which priority for transfer to the intensive care unit (ICU)?
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1. Priority 1 ix




2. Priority 2 ix




3. Priority 3 ix




4. Priority 4 ix




Correct Answer: 1 ix ix




Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other
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intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment
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and monitoring 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
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interventions. 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
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illnesses. Limits are placed on therapeutic interventions and they can be cared for in areas other than
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the ICU if necessary.
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Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment
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are necessary.
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Global Rationale: ix




Cognitive Level: Analyzing ix ix




Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
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ix Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-1 ix ix ix ix ix ix ix




Question 2 Type: MCSA ix ix ix




The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care
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unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father
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may 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. Discuss the care that can be provided on the unit with the family member.
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2|P a g e
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,4. Contact the physician. ix ix




Correct Answer: 3 ix ix




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.
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Bringing up the issue of cost may cause the daughter to offer to pay the difference between the costs of
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the two 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
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that 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
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Rationale:
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Cognitive Level: Analyzing ix ix




Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
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ix Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-1 ix ix ix ix ix ix ix




Question 3 Type: MCSA ix ix ix




A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and
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weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care
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environment?
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1. Feels comfortable in ever changing situations ix ix ix ix ix




2. Closely evaluates 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 all new experiences Correct Answer: 1
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Rationale 1: The nurse in the intensive care unit must be open to ever-changing situations. The nurse must
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be flexible.
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Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when considering
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actions.
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Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high- acuity
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care unit due to the need for teamwork and interaction.
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Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the
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most important factor for this particular care unit.
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Global Rationale: ix




Cognitive Level: Analyzing ix ix




Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
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3|P a g e
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, Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 ix ix ix ix ix ix ix




Question 4 Type: MCSA ix ix ix




The registered nurse is working as charge nurse on a busy high-acuity care unit. Unexpectedly, a
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coworker becomes ill and needs to leave. There is a period of time in which the unit is short staffed
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while the ill coworkers replacement travels in to work. What action by the charge nurse is indicated?
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1. Make no changes until the replacement nurse arrives.
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2. Assign the less acute patients to be cared for by the unlicensed assistive personnel.
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3. Assign the unlicensed assistive personnel to watch the monitors and call for help if a patient gets into
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trouble.
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4. Contact the house supervisor and ask for a float nurse to be sent to the unit. Correct Answer: 4
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Rationale 1: The unit is understaffed. Replacement help must be provided. It is inappropriate to wait for
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the replacement nurse.
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Rationale 2: The unlicensed assistive personnel are only able to provide care under the direct supervision
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of the nurse.
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Rationale 3: Watching monitors is not within the job description of the unlicensed assistive personnel and
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is not appropriate. The manager would be putting both patient safety and the unlicensed assistive
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personnel at risk.
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Rationale 4: The manager should obtain help until the replacement nurse arrives. Contacting the house
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supervisor and asking for a temporary float nurse is the best intervention.
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Global Rationale: ix




Cognitive Level: Analyzing ix ix




Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
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ix Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-2 ix ix ix ix ix ix ix




Question 5 Type: MCSA ix ix ix




A recent nursing school graduate reports having an interview with a magnet hospital. When preparing
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for the interview, the graduate nurse researches the concept of magnet status. Which perceptions by the
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nurse indicate an adequate understanding?
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1. Magnet status is an accreditation from the National League for Nurses.
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2. Magnet status facilities pay substantial recruitment bonuses.
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3. Magnet status facilities promote the interests of professional nursing.
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4. Magnet status hospitals must establish nurse-to-patient ratios. Correct Answer: 3
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4|P a g e
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