Test Bank for High-Acuity Nursing 7th
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t Edition
by Kathleen Wagner, Melanie Hardin-
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t Pierce, Darlene Welsh & Karen Johnson
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All Chapters 1-39 With Rationales| A+ PASS
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1|P a g e
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, Chapter 1. High-Acuity Nursing t t t
Question 1 t
Type: MCSA
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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
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to be which priority for transfer to the intensive care unit (ICU)?
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1. Priority 1 t
2. Priority 2 t
3. Priority 3 t
4. Priority 4 t
Correct Answer: 1 t t
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 and
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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.
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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
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necessary.
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Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment are
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necessary.
t
Global Rationale: t
Cognitive Level: Analyzing t t
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated
t t t t t t t t t t t t
Concepts: Nursing Process: Planning Learning Outcome: 1-1
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Question 2 Type: MCSA t t t
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care
t t t t t t t t t t t t t t t t t
unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father
t t t t t t t t t t t t t t t t t t
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. t t t t t t t t
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. t t
Correct Answer: 3 t t
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.
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Bringing up the issue of cost may cause the daughter to offer to pay the difference between the costs of the
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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 that
t t t t t t t t t t t t t t t t t t
will be provided on the MSCU so as to help her understand that her fathers care will be a priority.
t t t t t t t t t t t t t t t t t t t t
Rationale 4: The nurse should try to intervene in this situation before involving the physician. Global
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Rationale:
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Cognitive Level: Analyzing t t
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated
t t t t t t t t t t t t
Concepts: Nursing Process: Implementation Learning Outcome: 1-1
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Question 3 Type: MCSA t t t
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and
t t t t t t t t t t t t t t t t t
weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care
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environment?
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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-changing situations. The nurse must be
t t t t t t t t t t t t t t t t t t
flexible.
t
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when considering
t t t t t t t t t t t t t t t t t
actions.
t
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high- acuity care
t t t t t t t t t t t t t t t t t t t
unit due to the need for teamwork and interaction.
t t t t t t t t t
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the most
t t t t t t t t t t t t t t t t
important factor for this particular care unit.
t t t t t t t
Global Rationale: t
Cognitive Level: Analyzing t t
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
t t t t t t t t t t t
3|P a g e
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, Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 t t t t t t t
Question 4 Type: MCSA t t t
The registered nurse is working as charge nurse on a busy high-acuity care unit. Unexpectedly, a coworker
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becomes ill and needs to leave. There is a period of time in which the unit is short staffed while the ill
t t t t t t t t t t t t t t t t t t t t t t
coworkers replacement travels in to work. What action by the charge nurse is indicated?
t t t t t t t t t t t t t t
1. Make no changes until the replacement nurse arrives.
t t t t t t t
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
t t t t t t t t t t t t t t t t t
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 for the
t t t t t t t t t t t t t t t t t
replacement nurse.
t t
Rationale 2: The unlicensed assistive personnel are only able to provide care under the direct supervision of
t t t t t t t t t t t t t t t t
the nurse.
t t
Rationale 3: Watching monitors is not within the job description of the unlicensed assistive personnel and is
t t t t t t t t t t t t t t t t
not appropriate. The manager would be putting both patient safety and the unlicensed assistive personnel at
t t t t t t t t t t t t t t t t
risk.
t
Rationale 4: The manager should obtain help until the replacement nurse arrives. Contacting the house
t t t t t t t t t t t t t t
supervisor and asking for a temporary float nurse is the best intervention.
t t t t t t t t t t t t
Global Rationale: t
Cognitive Level: Analyzing t t
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated
t t t t t t t t t t t t
Concepts: Nursing Process: Implementation Learning Outcome: 1-2
t t t t t t t
Question 5 Type: MCSA t t t
A recent nursing school graduate reports having an interview with a magnet hospital. When preparing for
t t t t t t t t t t t t t t t
the interview, the graduate nurse researches the concept of magnet status. Which perceptions by the nurse
t t t t t t t t t t t t t t t t
indicate an adequate understanding?
t t t t
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
t t t t t
t t t t t
t Edition
by Kathleen Wagner, Melanie Hardin-
t t t t
t Pierce, Darlene Welsh & Karen Johnson
t t t t t
All Chapters 1-39 With Rationales| A+ PASS
t t t t t t
1|P a g e
t t t t t
, Chapter 1. High-Acuity Nursing t t t
Question 1 t
Type: MCSA
t t
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate of 29,
t t t t t t t t t t t t t t t t
inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this patient
t t t t t t t t t t t t t t t
to be which priority for transfer to the intensive care unit (ICU)?
t t t t t t t t t t t t
1. Priority 1 t
2. Priority 2 t
3. Priority 3 t
4. Priority 4 t
Correct Answer: 1 t t
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other
t t t t t t t t t t t t t t t t
intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment and
t t t t t t t t t t t t t t t t
monitoring not provided outside of the ICU.
t t t t t t t
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additional
t t t t t t t t t t t t t t
interventions. They are typically not evolving an acute event as is the case with this patient.
t t t t t t t t t t t t t t t t
Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their illnesses.
t t t t t t t t t t t t t t t t
Limits are placed on therapeutic interventions and they can be cared for in areas other than the ICU if
t t t t t t t t t t t t t t t t t t t
necessary.
t
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment are
t t t t t t t t t t t t t t t t
necessary.
t
Global Rationale: t
Cognitive Level: Analyzing t t
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated
t t t t t t t t t t t t
Concepts: Nursing Process: Planning Learning Outcome: 1-1
t t t t t t t
Question 2 Type: MCSA t t t
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care
t t t t t t t t t t t t t t t t t
unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father
t t t t t t t t t t t t t t t t t t
may not receive close observation on a busy hospital unit. Which action is indicated by the nurse?
t t t t t t t t t t t t t t t t t
1. Notify the intensive care unit of an impending transfer. t t t t t t t t
2. Tell the daughter that her father does not meet criteria for placement in the more expensive ICU.
t t t t t t t t t t t t t t t t
3. Discuss the care that can be provided on the unit with the family member.
t t t t t t t t t t t t t
2|P a g e
t t t t t
,4. Contact the physician. t t
Correct Answer: 3 t t
Rationale 1: The nurse cannot make this transfer decision independently.
t t t t t t t t t
Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not therapeutic.
t t t t t t t t t t t t t t t t
Bringing up the issue of cost may cause the daughter to offer to pay the difference between the costs of the
t t t t t t t t t t t t t t t t t t t t t
two units. This would create a serious ethical dilemma.
t t t t t t t t t
Rationale 3: The best initial response is to help the daughter understand the level of care and observation that
t t t t t t t t t t t t t t t t t t
will be provided on the MSCU so as to help her understand that her fathers care will be a priority.
t t t t t t t t t t t t t t t t t t t t
Rationale 4: The nurse should try to intervene in this situation before involving the physician. Global
t t t t t t t t t t t t t t t
Rationale:
t
Cognitive Level: Analyzing t t
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated
t t t t t t t t t t t t
Concepts: Nursing Process: Implementation Learning Outcome: 1-1
t t t t t t t
Question 3 Type: MCSA t t t
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and
t t t t t t t t t t t t t t t t t
weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care
t t t t t t t t t t t t t t t t
environment?
t
1. Feels comfortable in ever changing situations
t t t t t
2. Closely evaluates the pros and cons of each decision for a long period of time before making a decision
t t t t t t t t t t t t t t t t t t
3. Is quiet and introverted
t t t
4. Is excited about all new experiences Correct Answer: 1
t t t t t t t t
Rationale 1: The nurse in the intensive care unit must be open to ever-changing situations. The nurse must be
t t t t t t t t t t t t t t t t t t
flexible.
t
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when considering
t t t t t t t t t t t t t t t t t
actions.
t
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high- acuity care
t t t t t t t t t t t t t t t t t t t
unit due to the need for teamwork and interaction.
t t t t t t t t t
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the most
t t t t t t t t t t t t t t t t
important factor for this particular care unit.
t t t t t t t
Global Rationale: t
Cognitive Level: Analyzing t t
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
t t t t t t t t t t t
3|P a g e
t t t t t
, Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 t t t t t t t
Question 4 Type: MCSA t t t
The registered nurse is working as charge nurse on a busy high-acuity care unit. Unexpectedly, a coworker
t t t t t t t t t t t t t t t t
becomes ill and needs to leave. There is a period of time in which the unit is short staffed while the ill
t t t t t t t t t t t t t t t t t t t t t t
coworkers replacement travels in to work. What action by the charge nurse is indicated?
t t t t t t t t t t t t t t
1. Make no changes until the replacement nurse arrives.
t t t t t t t
2. Assign the less acute patients to be cared for by the unlicensed assistive personnel.
t t t t t t t t t t t t t
3. Assign the unlicensed assistive personnel to watch the monitors and call for help if a patient gets into
t t t t t t t t t t t t t t t t t
trouble.
t
4. Contact the house supervisor and ask for a float nurse to be sent to the unit. Correct Answer: 4
t t t t t t t t t t t t t t t t t t
Rationale 1: The unit is understaffed. Replacement help must be provided. It is inappropriate to wait for the
t t t t t t t t t t t t t t t t t
replacement nurse.
t t
Rationale 2: The unlicensed assistive personnel are only able to provide care under the direct supervision of
t t t t t t t t t t t t t t t t
the nurse.
t t
Rationale 3: Watching monitors is not within the job description of the unlicensed assistive personnel and is
t t t t t t t t t t t t t t t t
not appropriate. The manager would be putting both patient safety and the unlicensed assistive personnel at
t t t t t t t t t t t t t t t t
risk.
t
Rationale 4: The manager should obtain help until the replacement nurse arrives. Contacting the house
t t t t t t t t t t t t t t
supervisor and asking for a temporary float nurse is the best intervention.
t t t t t t t t t t t t
Global Rationale: t
Cognitive Level: Analyzing t t
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated
t t t t t t t t t t t t
Concepts: Nursing Process: Implementation Learning Outcome: 1-2
t t t t t t t
Question 5 Type: MCSA t t t
A recent nursing school graduate reports having an interview with a magnet hospital. When preparing for
t t t t t t t t t t t t t t t
the interview, the graduate nurse researches the concept of magnet status. Which perceptions by the nurse
t t t t t t t t t t t t t t t t
indicate an adequate understanding?
t t t t
1. Magnet status is an accreditation from the National League for Nurses.
t t t t t t t t t t
2. Magnet status facilities pay substantial recruitment bonuses.
t t t t t t
3. Magnet status facilities promote the interests of professional nursing.
t t t t t t t t
4. Magnet status hospitals must establish nurse-to-patient ratios. Correct Answer: 3
t t t t t t t t t
4|P a g e
t t t t t
