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