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