Test Bank for High-Acuity Nursing 7th
b b b b b
Edition
b
by Kathleen Wagner, Melanie Hardin-
b b b b
Pierce, Darlene Welsh & Karen Johnson
b b b b b b
All Chapters 1-39 With Rationales| A+ PASS
b b b b b b
1|P a g e
b b b b b
, Chapter 1. High-Acuity Nursing b b b
Question 1 b
Type:
b
MCSA
b
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate of
b b b b b b b b b b b b b b b
29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this
b b b b b b b b b b b b b b b
patient to be which priority for transfer to the intensive care unit (ICU)?
b b b b b b b b b b b b b
1. Priority 1 b
2. Priority 2 b
3. Priority 3 b
4. Priority 4 b
Correct Answer: 1 b b
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other
b b b b b b b b b b b b b b b b
intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment
b b b b b b b b b b b b b b b
and monitoring not provided outside of the ICU.
b b b b b b b b
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additional
b b b b b b b b b b b b b b
interventions. They are typically not evolving an acute event as is the case with this patient.
b b b b b b b b b b b b b b b b
Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their
b b b b b b b b b b b b b b b
illnesses. Limits are placed on therapeutic interventions and they can be cared for in areas other than
b b b b b b b b b b b b b b b b b
the ICU if necessary.
b b b b
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment
b b b b b b b b b b b b b b b
are necessary.
b b
Global Rationale: b
Cognitive Level: Analyzing b b
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
b b b b b b b b b b b
Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-1
b b b b b b b b
Question 2 Type: MCSA b b b
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care
b b b b b b b b b b b b b b b b b
unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father
b b b b b b b b b b b b b b b b b b
may not receive close observation on a busy hospital unit. Which action is indicated by the nurse?
b b b b b b b b b b b b b b b b b
1. Notify the intensive care unit of an impending transfer.
b b b b b b b b
2. Tell the daughter that her father does not meet criteria for placement in the more expensive ICU.
b b b b b b b b b b b b b b b b
3. Discuss the care that can be provided on the unit with the family member.
b b b b b b b b b b b b b
2|P a g e
b b b b b
,4. Contact the physician. b b
Correct Answer: 3 b b
Rationale 1: The nurse cannot make this transfer decision independently.
b b b b b b b b b
Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not therapeutic.
b b b b b b b b b b b b b b b b
Bringing up the issue of cost may cause the daughter to offer to pay the difference between the costs of
b b b b b b b b b b b b b b b b b b b b
the two units. This would create a serious ethical dilemma.
b b b b b b b b b b
Rationale 3: The best initial response is to help the daughter understand the level of care and observation
b b b b b b b b b b b b b b b b b
that will be provided on the MSCU so as to help her understand that her fathers care will be a priority.
b b b b b b b b b b b b b b b b b b b b b
Rationale 4: The nurse should try to intervene in this situation before involving the physician. Global
b b b b b b b b b b b b b b b
Rationale:
b
Cognitive Level: Analyzing b b
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
b b b b b b b b b b b
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-1
b b b b b b b b
Question 3 Type: MCSA b b b
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and
b b b b b b b b b b b b b b b b b
weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care
b b b b b b b b b b b b b b b b
environment?
b
1. Feels comfortable in ever changing situations
b b b b b
2. Closely evaluates the pros and cons of each decision for a long period of time before making a decision
b b b b b b b b b b b b b b b b b b
3. Is quiet and introverted
b b b
4. Is excited about all new experiences Correct Answer: 1
b b b b b b b b
Rationale 1: The nurse in the intensive care unit must be open to ever-changing situations. The nurse must
b b b b b b b b b b b b b b b b b
be flexible.
b b
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when considering
b b b b b b b b b b b b b b b b b
actions.
b
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high- acuity
b b b b b b b b b b b b b b b b b b
care unit due to the need for teamwork and interaction.
b b b b b b b b b b
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the
b b b b b b b b b b b b b b b
most important factor for this particular care unit.
b b b b b b b b
Global Rationale: b
Cognitive Level: Analyzing b b
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
b b b b b b b b b b b
3|P a g e
b b b b b
, Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 b b b b b b b
Question 4 Type: MCSA b b b
The registered nurse is working as charge nurse on a busy high-acuity care unit. Unexpectedly, a
b b b b b b b b b b b b b b b
coworker becomes ill and needs to leave. There is a period of time in which the unit is short staffed
b b b b b b b b b b b b b b b b b b b b
while the ill coworkers replacement travels in to work. What action by the charge nurse is indicated?
b b b b b b b b b b b b b b b b b
1. Make no changes until the replacement nurse arrives.
b b b b b b b
2. Assign the less acute patients to be cared for by the unlicensed assistive personnel.
b b b b b b b b b b b b b
3. Assign the unlicensed assistive personnel to watch the monitors and call for help if a patient gets into
b b b b b b b b b b b b b b b b b
trouble.
b
4. Contact the house supervisor and ask for a float nurse to be sent to the unit. Correct Answer: 4
b b b b b b b b b b b b b b b b b b
Rationale 1: The unit is understaffed. Replacement help must be provided. It is inappropriate to wait for
b b b b b b b b b b b b b b b b
the replacement nurse.
b b b
Rationale 2: The unlicensed assistive personnel are only able to provide care under the direct supervision
b b b b b b b b b b b b b b b
of the nurse.
b b b
Rationale 3: Watching monitors is not within the job description of the unlicensed assistive personnel and
b b b b b b b b b b b b b b b
is not appropriate. The manager would be putting both patient safety and the unlicensed assistive
b b b b b b b b b b b b b b b
personnel at risk.
b b b
Rationale 4: The manager should obtain help until the replacement nurse arrives. Contacting the house
b b b b b b b b b b b b b b
supervisor and asking for a temporary float nurse is the best intervention.
b b b b b b b b b b b b
Global Rationale: b
Cognitive Level: Analyzing b b
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
b b b b b b b b b b b
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-2
b b b b b b b b
Question 5 Type: MCSA b b b
A recent nursing school graduate reports having an interview with a magnet hospital. When preparing
b b b b b b b b b b b b b b
for the interview, the graduate nurse researches the concept of magnet status. Which perceptions by the
b b b b b b b b b b b b b b b b
nurse indicate an adequate understanding?
b b b b b
1. Magnet status is an accreditation from the National League for Nurses.
b b b b b b b b b b
2. Magnet status facilities pay substantial recruitment bonuses.
b b b b b b
3. Magnet status facilities promote the interests of professional nursing.
b b b b b b b b
4. Magnet status hospitals must establish nurse-to-patient ratios. Correct Answer: 3
b b b b b b b b b
4|P a g e
b b b b b
b b b b b
Edition
b
by Kathleen Wagner, Melanie Hardin-
b b b b
Pierce, Darlene Welsh & Karen Johnson
b b b b b b
All Chapters 1-39 With Rationales| A+ PASS
b b b b b b
1|P a g e
b b b b b
, Chapter 1. High-Acuity Nursing b b b
Question 1 b
Type:
b
MCSA
b
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate of
b b b b b b b b b b b b b b b
29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this
b b b b b b b b b b b b b b b
patient to be which priority for transfer to the intensive care unit (ICU)?
b b b b b b b b b b b b b
1. Priority 1 b
2. Priority 2 b
3. Priority 3 b
4. Priority 4 b
Correct Answer: 1 b b
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other
b b b b b b b b b b b b b b b b
intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment
b b b b b b b b b b b b b b b
and monitoring not provided outside of the ICU.
b b b b b b b b
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additional
b b b b b b b b b b b b b b
interventions. They are typically not evolving an acute event as is the case with this patient.
b b b b b b b b b b b b b b b b
Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their
b b b b b b b b b b b b b b b
illnesses. Limits are placed on therapeutic interventions and they can be cared for in areas other than
b b b b b b b b b b b b b b b b b
the ICU if necessary.
b b b b
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment
b b b b b b b b b b b b b b b
are necessary.
b b
Global Rationale: b
Cognitive Level: Analyzing b b
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
b b b b b b b b b b b
Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-1
b b b b b b b b
Question 2 Type: MCSA b b b
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care
b b b b b b b b b b b b b b b b b
unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father
b b b b b b b b b b b b b b b b b b
may not receive close observation on a busy hospital unit. Which action is indicated by the nurse?
b b b b b b b b b b b b b b b b b
1. Notify the intensive care unit of an impending transfer.
b b b b b b b b
2. Tell the daughter that her father does not meet criteria for placement in the more expensive ICU.
b b b b b b b b b b b b b b b b
3. Discuss the care that can be provided on the unit with the family member.
b b b b b b b b b b b b b
2|P a g e
b b b b b
,4. Contact the physician. b b
Correct Answer: 3 b b
Rationale 1: The nurse cannot make this transfer decision independently.
b b b b b b b b b
Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not therapeutic.
b b b b b b b b b b b b b b b b
Bringing up the issue of cost may cause the daughter to offer to pay the difference between the costs of
b b b b b b b b b b b b b b b b b b b b
the two units. This would create a serious ethical dilemma.
b b b b b b b b b b
Rationale 3: The best initial response is to help the daughter understand the level of care and observation
b b b b b b b b b b b b b b b b b
that will be provided on the MSCU so as to help her understand that her fathers care will be a priority.
b b b b b b b b b b b b b b b b b b b b b
Rationale 4: The nurse should try to intervene in this situation before involving the physician. Global
b b b b b b b b b b b b b b b
Rationale:
b
Cognitive Level: Analyzing b b
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
b b b b b b b b b b b
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-1
b b b b b b b b
Question 3 Type: MCSA b b b
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and
b b b b b b b b b b b b b b b b b
weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care
b b b b b b b b b b b b b b b b
environment?
b
1. Feels comfortable in ever changing situations
b b b b b
2. Closely evaluates the pros and cons of each decision for a long period of time before making a decision
b b b b b b b b b b b b b b b b b b
3. Is quiet and introverted
b b b
4. Is excited about all new experiences Correct Answer: 1
b b b b b b b b
Rationale 1: The nurse in the intensive care unit must be open to ever-changing situations. The nurse must
b b b b b b b b b b b b b b b b b
be flexible.
b b
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when considering
b b b b b b b b b b b b b b b b b
actions.
b
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high- acuity
b b b b b b b b b b b b b b b b b b
care unit due to the need for teamwork and interaction.
b b b b b b b b b b
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the
b b b b b b b b b b b b b b b
most important factor for this particular care unit.
b b b b b b b b
Global Rationale: b
Cognitive Level: Analyzing b b
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
b b b b b b b b b b b
3|P a g e
b b b b b
, Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 b b b b b b b
Question 4 Type: MCSA b b b
The registered nurse is working as charge nurse on a busy high-acuity care unit. Unexpectedly, a
b b b b b b b b b b b b b b b
coworker becomes ill and needs to leave. There is a period of time in which the unit is short staffed
b b b b b b b b b b b b b b b b b b b b
while the ill coworkers replacement travels in to work. What action by the charge nurse is indicated?
b b b b b b b b b b b b b b b b b
1. Make no changes until the replacement nurse arrives.
b b b b b b b
2. Assign the less acute patients to be cared for by the unlicensed assistive personnel.
b b b b b b b b b b b b b
3. Assign the unlicensed assistive personnel to watch the monitors and call for help if a patient gets into
b b b b b b b b b b b b b b b b b
trouble.
b
4. Contact the house supervisor and ask for a float nurse to be sent to the unit. Correct Answer: 4
b b b b b b b b b b b b b b b b b b
Rationale 1: The unit is understaffed. Replacement help must be provided. It is inappropriate to wait for
b b b b b b b b b b b b b b b b
the replacement nurse.
b b b
Rationale 2: The unlicensed assistive personnel are only able to provide care under the direct supervision
b b b b b b b b b b b b b b b
of the nurse.
b b b
Rationale 3: Watching monitors is not within the job description of the unlicensed assistive personnel and
b b b b b b b b b b b b b b b
is not appropriate. The manager would be putting both patient safety and the unlicensed assistive
b b b b b b b b b b b b b b b
personnel at risk.
b b b
Rationale 4: The manager should obtain help until the replacement nurse arrives. Contacting the house
b b b b b b b b b b b b b b
supervisor and asking for a temporary float nurse is the best intervention.
b b b b b b b b b b b b
Global Rationale: b
Cognitive Level: Analyzing b b
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
b b b b b b b b b b b
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-2
b b b b b b b b
Question 5 Type: MCSA b b b
A recent nursing school graduate reports having an interview with a magnet hospital. When preparing
b b b b b b b b b b b b b b
for the interview, the graduate nurse researches the concept of magnet status. Which perceptions by the
b b b b b b b b b b b b b b b b
nurse indicate an adequate understanding?
b b b b b
1. Magnet status is an accreditation from the National League for Nurses.
b b b b b b b b b b
2. Magnet status facilities pay substantial recruitment bonuses.
b b b b b b
3. Magnet status facilities promote the interests of professional nursing.
b b b b b b b b
4. Magnet status hospitals must establish nurse-to-patient ratios. Correct Answer: 3
b b b b b b b b b
4|P a g e
b b b b b
