hapter 1. High-Acuity Nursing nm nm nm
Question 1 T nm nm
ype: MCSA nm
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate
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of 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider t
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his patient to be which priority for transfer to the intensive care unit (ICU)?
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1. Priority 1 nm
2. Priority 2 nm
3. Priority 3 nm
4. Priority 4 nm
Correct Answer: 1 nm nm
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or oth
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er intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatme
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nt 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 i
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nterventions. 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 illnes
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ses. Limits are placed on therapeutic interventions and they can be cared for in areas other than th
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e ICU if necessary.
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,Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatme
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nt are necessary.
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Global Rationale: nm
Cognitive Level: Analyzing nm nm
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integr
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ated Concepts: Nursing Process: Planning Learning Outcome: 1-1
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Question 2 Type: MCSA nm nm nm
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical
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care unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern he
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r father may not receive close observation on a busy hospital unit. Which action is indicated by the
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nurse?
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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,4. Contact the physician nm nm
.
Correct Answer: 3 nm nm
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
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of 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 observati
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on that will be provided on the MSCU so as to help her understand that her fathers care will be a pri
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ority.
Rationale 4: The nurse should try to intervene in this situation before involving the physician. Global
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Rationale:
Cognitive Level: Analyzing nm nm
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integ
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rated Concepts: Nursing Process: Implementation Learning Outcome: 1-1
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Question 3 Type: MCSA nm nm nm
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths an
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d weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care
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environment?
1. Feels comfortable in ever changing situations
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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-
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changing situations. The nurse must 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.
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-
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acuity 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: nm
Cognitive Level: Analyzing nm nm
3|P a g e
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, Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
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4|P a g e
nm nm nm nm nm
Question 1 T nm nm
ype: MCSA nm
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
of 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider t
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
his patient to be which priority for transfer to the intensive care unit (ICU)?
nm nm nm nm nm nm nm nm nm nm nm nm nm
1. Priority 1 nm
2. Priority 2 nm
3. Priority 3 nm
4. Priority 4 nm
Correct Answer: 1 nm nm
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or oth
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
er intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatme
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
nt and monitoring not provided outside of the ICU.
nm nm nm nm nm nm nm nm
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additional i
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
nterventions. They are typically not evolving an acute event as is the case with this patient.
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their illnes
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
ses. Limits are placed on therapeutic interventions and they can be cared for in areas other than th
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
e ICU if necessary.
nm nm nm
1|P a g e
nm nm nm nm nm
,Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatme
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nt are necessary.
nm nm
Global Rationale: nm
Cognitive Level: Analyzing nm nm
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integr
nm nm nm nm nm nm nm nm nm nm nm nm
ated Concepts: Nursing Process: Planning Learning Outcome: 1-1
nm nm nm nm nm nm nm
Question 2 Type: MCSA nm nm nm
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
care unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern he
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
r father may not receive close observation on a busy hospital unit. Which action is indicated by the
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
nurse?
1. Notify the intensive care unit of an impending transfer.
nm nm nm nm nm nm nm nm
2. Tell the daughter that her father does not meet criteria for placement in the more expensive ICU.
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
3. Discuss the care that can be provided on the unit with the family member.
nm nm nm nm nm nm nm nm nm nm nm nm nm
2|P a g e
nm nm nm nm nm
,4. Contact the physician nm nm
.
Correct Answer: 3 nm nm
Rationale 1: The nurse cannot make this transfer decision independently.
nm nm nm nm nm nm nm nm nm
Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not therapeutic.
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
Bringing up the issue of cost may cause the daughter to offer to pay the difference between the costs
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
of the two units. This would create a serious ethical dilemma.
nm nm nm nm nm nm nm nm nm nm
Rationale 3: The best initial response is to help the daughter understand the level of care and observati
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
on that will be provided on the MSCU so as to help her understand that her fathers care will be a pri
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
ority.
Rationale 4: The nurse should try to intervene in this situation before involving the physician. Global
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
Rationale:
Cognitive Level: Analyzing nm nm
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integ
nm nm nm nm nm nm nm nm nm nm nm nm
rated Concepts: Nursing Process: Implementation Learning Outcome: 1-1
nm nm nm nm nm nm nm
Question 3 Type: MCSA nm nm nm
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths an
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
d weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
environment?
1. Feels comfortable in ever changing situations
nm nm nm nm nm
2. Closely evaluates the pros and cons of each decision for a long period of time before making a decision
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
3. Is quiet and introverted
nm nm nm
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-
nm nm nm nm nm nm nm nm nm nm nm nm nm
changing situations. The nurse must be flexible.
nm nm nm nm nm nm
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when considering
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
actions.
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
acuity care unit due to the need for teamwork and interaction.
nm nm nm nm nm nm nm nm nm nm nm
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the
nm nm nm nm nm nm nm nm nm nm nm nm nm nm nm
most important factor for this particular care unit.
nm nm nm nm nm nm nm nm
Global Rationale: nm
Cognitive Level: Analyzing nm nm
3|P a g e
nm nm nm nm nm
, Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
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4|P a g e
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