1|P a g e
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, Chapter 1. High-Acuity Nursing mf mf mf
Question 1 T mf mf
ype: MCSA mf
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate o
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f 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this
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patient to be which priority for transfer to the intensive care unit (ICU)?
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1. Priority 1 mf
2. Priority 2 mf
3. Priority 3 mf
4. Priority 4 mf
Correct Answer: 1 mf mf
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other
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intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment a
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nd 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 int
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erventions. 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 illnesse
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s. Limits are placed on therapeutic interventions and they can be cared for in areas other than the IC
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U if necessary.
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Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatmen
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t are necessary.
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Global Rationale: mf
Cognitive Level: Analyzing mf mf
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrat
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ed Concepts: Nursing Process: Planning Learning Outcome: 1-1
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Question 2 Type: MCSA mf mf mf
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical ca
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re unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her fat
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her may 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
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,4. Contact the physician. mf mf
Correct Answer: 3 mf mf
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. B
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ringing up the issue of cost may cause the daughter to offer to pay the difference between the costs of t
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he 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 observation
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that 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 R
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ationale:
Cognitive Level: Analyzing mf mf
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integra
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ted Concepts: Nursing Process: Implementation Learning Outcome: 1-1
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Question 3 Type: MCSA mf mf mf
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and
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weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care env
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ironment?
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 ac
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tions.
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: mf
Cognitive Level: Analyzing mf mf
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
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3|P a g e
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, Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 mf mf mf mf mf mf mf
Question 4 Type: MCSA mf mf mf
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
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which the unit is short staffed while the ill coworkers replacement travels in to work. What action by th
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e charge 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 int
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o trouble.
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4. Contact the house supervisor and ask for a float nurse to be sent to the unit. Correct Answer: 4
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Rationale 1: The unit is understaffed. Replacement help must be provided. It is inappropriate to wait fo
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r the replacement nurse.
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Rationale 2: The unlicensed assistive personnel are only able to provide care under the direct supervision
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of the nurse.
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Rationale 3: Watching monitors is not within the job description of the unlicensed assistive personnel an
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d is not appropriate. The manager would be putting both patient safety and the unlicensed assistive pers
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onnel at risk. mf mf
Rationale 4: The manager should obtain help until the replacement nurse arrives. Contacting the house
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supervisor and asking for a temporary float nurse is the best intervention.
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Global Rationale: mf
Cognitive Level: Analyzing mf mf
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integra
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ted Concepts: Nursing Process: Implementation Learning Outcome: 1-2
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Question 5 Type: MCSA mf mf mf
A recent nursing school graduate reports having an interview with a magnet hospital. When preparing f
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or the interview, the graduate nurse researches the concept of magnet status. Which perceptions by the n
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urse indicate an adequate understanding?
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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
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, Chapter 1. High-Acuity Nursing mf mf mf
Question 1 T mf mf
ype: MCSA mf
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate o
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f 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this
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patient to be which priority for transfer to the intensive care unit (ICU)?
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1. Priority 1 mf
2. Priority 2 mf
3. Priority 3 mf
4. Priority 4 mf
Correct Answer: 1 mf mf
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other
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intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment a
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nd 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 int
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erventions. 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 illnesse
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s. Limits are placed on therapeutic interventions and they can be cared for in areas other than the IC
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U if necessary.
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Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatmen
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t are necessary.
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Global Rationale: mf
Cognitive Level: Analyzing mf mf
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrat
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ed Concepts: Nursing Process: Planning Learning Outcome: 1-1
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Question 2 Type: MCSA mf mf mf
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical ca
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re unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her fat
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her may 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
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,4. Contact the physician. mf mf
Correct Answer: 3 mf mf
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. B
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ringing up the issue of cost may cause the daughter to offer to pay the difference between the costs of t
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he 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 observation
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that 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 R
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ationale:
Cognitive Level: Analyzing mf mf
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integra
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ted Concepts: Nursing Process: Implementation Learning Outcome: 1-1
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Question 3 Type: MCSA mf mf mf
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and
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weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care env
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ironment?
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 ac
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tions.
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: mf
Cognitive Level: Analyzing mf mf
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
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3|P a g e
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, Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 mf mf mf mf mf mf mf
Question 4 Type: MCSA mf mf mf
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
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which the unit is short staffed while the ill coworkers replacement travels in to work. What action by th
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e charge 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 int
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o trouble.
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4. Contact the house supervisor and ask for a float nurse to be sent to the unit. Correct Answer: 4
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Rationale 1: The unit is understaffed. Replacement help must be provided. It is inappropriate to wait fo
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r the replacement nurse.
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Rationale 2: The unlicensed assistive personnel are only able to provide care under the direct supervision
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of the nurse.
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Rationale 3: Watching monitors is not within the job description of the unlicensed assistive personnel an
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d is not appropriate. The manager would be putting both patient safety and the unlicensed assistive pers
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onnel at risk. mf mf
Rationale 4: The manager should obtain help until the replacement nurse arrives. Contacting the house
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supervisor and asking for a temporary float nurse is the best intervention.
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Global Rationale: mf
Cognitive Level: Analyzing mf mf
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integra
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ted Concepts: Nursing Process: Implementation Learning Outcome: 1-2
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Question 5 Type: MCSA mf mf mf
A recent nursing school graduate reports having an interview with a magnet hospital. When preparing f
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or the interview, the graduate nurse researches the concept of magnet status. Which perceptions by the n
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urse indicate an adequate understanding?
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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
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