1|P a g e
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, Chapter 1. High-Acuity Nursing fg fg fg
Question 1 T fg fg
ype: MCSA fg
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate of 2
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9, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this patie
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nt to be which priority for transfer to the intensive care unit (ICU)?
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1. Priority 1 fg
2. Priority 2 fg
3. Priority 3 fg
4. Priority 4 fg
Correct Answer: 1 fg fg
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other in
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tensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment and mo
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nitoring not provided outside of the ICU.fg fg fg fg fg fg
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additional inter
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ventions. 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 illnesses.
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Limits are placed on therapeutic interventions and they can be cared for in areas other than the ICU if n
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ecessary.
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment ar
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e necessary.
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Global Rationale: fg
Cognitive Level: Analyzing fg fg
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated
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Concepts: Nursing Process: Planning Learning Outcome: 1-1
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Question 2 Type: MCSA fg fg fg
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care u
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nit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father ma
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y 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
fg fg fg fg fg
,4. Contact the physician. fg fg
Correct Answer: 3 fg fg
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. Brin
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ging up the issue of cost may cause the daughter to offer to pay the difference between the costs of the two
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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 tha
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
t 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 Ratio
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nale:
Cognitive Level: Analyzing fg fg
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrate
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d Concepts: Nursing Process: Implementation Learning Outcome: 1-1
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Question 3 Type: MCSA fg fg fg
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and we
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aknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care environm
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ent?
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. fg fg fg fg fg fg
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when considering actio
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ns.
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 mos
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t important factor for this particular care unit.
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Global Rationale: fg
Cognitive Level: Analyzing fg fg
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
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3|P a g e fg fg fg fg fg
, Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 fg fg fg fg fg fg fg
Question 4 Type: MCSA fg fg fg
The registered nurse is working as charge nurse on a busy high-
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acuity care unit. Unexpectedly, a coworker becomes ill and needs to leave. There is a period of time in whi
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
ch the unit is short staffed while the ill coworkers replacement travels in to work. What action by the charg
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e 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 tr
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ouble.
4. Contact the house supervisor and ask for a float nurse to be sent to the unit. Correct Answer: 4
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
Rationale 1: The unit is understaffed. Replacement help must be provided. It is inappropriate to wait for t
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
he replacement nurse.
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Rationale 2: The unlicensed assistive personnel are only able to provide care under the direct supervision of
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the nurse.
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Rationale 3: Watching monitors is not within the job description of the unlicensed assistive personnel and i
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s not appropriate. The manager would be putting both patient safety and the unlicensed assistive personnel
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
at risk.
fg fg
Rationale 4: The manager should obtain help until the replacement nurse arrives. Contacting the house su
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pervisor and asking for a temporary float nurse is the best intervention.
fg fg fg fg fg fg fg fg fg fg fg
Global Rationale: fg
Cognitive Level: Analyzing fg fg
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrate
fg fg fg fg fg fg fg fg fg fg fg fg
d Concepts: Nursing Process: Implementation Learning Outcome: 1-2
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Question 5 Type: MCSA fg fg fg
A recent nursing school graduate reports having an interview with a magnet hospital. When preparing for t
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he interview, the graduate nurse researches the concept of magnet status. Which perceptions by the nurse in
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dicate an adequate understanding?fg fg fg
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
fg fg fg fg fg
fg fg fg fg fg
, Chapter 1. High-Acuity Nursing fg fg fg
Question 1 T fg fg
ype: MCSA fg
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate of 2
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
9, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this patie
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
nt to be which priority for transfer to the intensive care unit (ICU)?
fg fg fg fg fg fg fg fg fg fg fg fg
1. Priority 1 fg
2. Priority 2 fg
3. Priority 3 fg
4. Priority 4 fg
Correct Answer: 1 fg fg
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other in
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tensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment and mo
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nitoring not provided outside of the ICU.fg fg fg fg fg fg
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additional inter
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ventions. 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 illnesses.
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Limits are placed on therapeutic interventions and they can be cared for in areas other than the ICU if n
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
ecessary.
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment ar
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e necessary.
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Global Rationale: fg
Cognitive Level: Analyzing fg fg
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated
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Concepts: Nursing Process: Planning Learning Outcome: 1-1
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Question 2 Type: MCSA fg fg fg
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care u
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
nit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father ma
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
y 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.
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
3. Discuss the care that can be provided on the unit with the family member.
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2|P a g e
fg fg fg fg fg
,4. Contact the physician. fg fg
Correct Answer: 3 fg fg
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. Brin
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
ging up the issue of cost may cause the daughter to offer to pay the difference between the costs of the two
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
units. This would create a serious ethical dilemma.
fg fg fg fg fg fg fg
Rationale 3: The best initial response is to help the daughter understand the level of care and observation tha
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
t will be provided on the MSCU so as to help her understand that her fathers care will be a priority.
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
Rationale 4: The nurse should try to intervene in this situation before involving the physician. Global Ratio
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
nale:
Cognitive Level: Analyzing fg fg
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrate
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d Concepts: Nursing Process: Implementation Learning Outcome: 1-1
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Question 3 Type: MCSA fg fg fg
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and we
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
aknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care environm
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
ent?
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. fg fg fg fg fg fg
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when considering actio
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
ns.
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
acuity care unit due to the need for teamwork and interaction.
fg fg fg fg fg fg fg fg fg fg fg
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the mos
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t important factor for this particular care unit.
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Global Rationale: fg
Cognitive Level: Analyzing fg fg
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
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3|P a g e fg fg fg fg fg
, Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 fg fg fg fg fg fg fg
Question 4 Type: MCSA fg fg fg
The registered nurse is working as charge nurse on a busy high-
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acuity care unit. Unexpectedly, a coworker becomes ill and needs to leave. There is a period of time in whi
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
ch the unit is short staffed while the ill coworkers replacement travels in to work. What action by the charg
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e nurse is indicated?
fg fg fg
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.
fg fg fg fg fg fg fg fg fg fg fg fg fg
3. Assign the unlicensed assistive personnel to watch the monitors and call for help if a patient gets into tr
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
ouble.
4. Contact the house supervisor and ask for a float nurse to be sent to the unit. Correct Answer: 4
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
Rationale 1: The unit is understaffed. Replacement help must be provided. It is inappropriate to wait for t
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
he replacement nurse.
fg fg
Rationale 2: The unlicensed assistive personnel are only able to provide care under the direct supervision of
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg f
the nurse.
g fg
Rationale 3: Watching monitors is not within the job description of the unlicensed assistive personnel and i
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
s not appropriate. The manager would be putting both patient safety and the unlicensed assistive personnel
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
at risk.
fg fg
Rationale 4: The manager should obtain help until the replacement nurse arrives. Contacting the house su
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
pervisor and asking for a temporary float nurse is the best intervention.
fg fg fg fg fg fg fg fg fg fg fg
Global Rationale: fg
Cognitive Level: Analyzing fg fg
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrate
fg fg fg fg fg fg fg fg fg fg fg fg
d Concepts: Nursing Process: Implementation Learning Outcome: 1-2
fg fg fg fg fg fg fg
Question 5 Type: MCSA fg fg fg
A recent nursing school graduate reports having an interview with a magnet hospital. When preparing for t
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
he interview, the graduate nurse researches the concept of magnet status. Which perceptions by the nurse in
fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg fg
dicate an adequate understanding?fg fg fg
1. Magnet status is an accreditation from the National League for Nurses.
fg fg fg fg fg fg fg fg fg fg
2. Magnet status facilities pay substantial recruitment bonuses.
fg fg fg fg fg fg
3. Magnet status facilities promote the interests of professional nursing.
fg fg fg fg fg fg fg fg
4. Magnet status hospitals must establish nurse-to-patient ratios. Correct Answer: 3
fg fg fg fg fg fg fg fg fg
4|P a g e
fg fg fg fg fg
