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