Test Bank for High-
7 7 7
Acuity Nursing 7th Editio
7 7 7
n
by Kathleen Wagner, Melanie Hardin-
7 7 7 7
7Pierce, Darlene Welsh & Karen Johnson
7 7 7 7 7
All Chapters 1-39 With Rationales| A+ PASS
7 7 7 7 7 7
17|7P7a7g7e
, Chapter71.7High-Acuity7Nursing
Question717T
ype:7MCSA
The7patient7who7had7surgery7yesterday7reports7his7chest7feels7tight.7Assessment7reveals7respiratory7rate7
of729,7inspiratory7wheezes,7stridor,7and7an7oxygenation7saturation7of780%.7The7nurse7would7consider7th
is7patient7to7be7which7priority7for7transfer7to7the7intensive7care7unit7(ICU)?
1. Priority71
2. Priority72
3. Priority73
4. Priority74
Correct7Answer:71
Rationale71:7This7patient7is7exhibiting7signs7of7an7acute7respiratory7event7for7which7intubation7or7othe
r7intensive7treatment7may7be7necessary.7Priority717patients7are7acutely7ill7and7need7intensive7treatment
7and7monitoring7not7provided7outside7of7the7ICU.
Rationale72:7Priority727refers7to7patients7needing7intensive7monitoring7and7may7potentially7need7additional7i
nterventions.7They7are7typically7not7evolving7an7acute7event7as7is7the7case7with7this7patient.
Rationale73:7Priority737patients7are7critically7ill7but7have7little7chance7of7recovery7from7their7illness
es.7Limits7are7placed7on7therapeutic7interventions7and7they7can7be7cared7for7in7areas7other7than7the7
ICU7if7necessary.
Rationale74:7Priority747patients7have7no7signs7or7symptoms7that7indicate7intensive7monitoring7or7treatme
nt7are7necessary.
Global7Rationale:
Cognitive7Level:7Analyzing
Client7Need:7Safe7Effective7Care7Environment7Client7Need7Sub:7Management7of7Care7Nursing/Integra
ted7Concepts:7Nursing7Process:7Planning7Learning7Outcome:71-1
Question727Type:7MCSA
The7daughter7of7a7patient7who7is7dying7questions7the7placement7of7her7father7on7the7medicalsurgical7c
are7unit7(MSCU).7She7requests7he7be7placed7in7the7intensive7care7unit7(ICU)7because7of7concern7her7f
ather7may7not7receive7close7observation7on7a7busy7hospital7unit.7Which7action7is7indicated7by7the7nurs
e?
1. Notify7the7intensive7care7unit7of7an7impending7transfer.
2. Tell7the7daughter7that7her7father7does7not7meet7criteria7for7placement7in7the7more7expensive7ICU.
3. Discuss7the7care7that7can7be7provided7on7the7unit7with7the7family7member.
27|7P7a7g7e
,4. Contact7the7physician.
Correct7Answer:73
Rationale71:7The7nurse7cannot7make7this7transfer7decision7independently.
Rationale72:7Telling7the7daughter7that7her7father7does7not7meet7criteria7for7transfer7is7not7therapeutic.7
Bringing7up7the7issue7of7cost7may7cause7the7daughter7to7offer7to7pay7the7difference7between7the7costs7o
f7the7two7units.7This7would7create7a7serious7ethical7dilemma.
Rationale73:7The7best7initial7response7is7to7help7the7daughter7understand7the7level7of7care7and7observatio
n7that7will7be7provided7on7the7MSCU7so7as7to7help7her7understand7that7her7fathers7care7will7be7a7priorit
y.
Rationale74:7The7nurse7should7try7to7intervene7in7this7situation7before7involving7the7physician.7Global7
Rationale:
Cognitive7Level:7Analyzing
Client7Need:7Safe7Effective7Care7Environment7Client7Need7Sub:7Management7of7Care7Nursing/Integr
ated7Concepts:7Nursing7Process:7Implementation7Learning7Outcome:71-1
Question737Type:7MCSA
A7nurse7who7is7contemplating7taking7a7position7in7an7intensive7care7unit7is7reviewing7her7strengths7an
d7weaknesses.7Which7characteristics7of7the7nurse7will7be7of7the7greatest7benefit7in7the7intensive7care7e
nvironment?
1. Feels7comfortable7in7ever7changing7situations
2. Closely7evaluates7the7pros7and7cons7of7each7decision7for7a7long7period7of7time7before7making7a7decision
3. Is7quiet7and7introverted
4. Is7excited7about7all7new7experiences7Correct7Answer:71
Rationale71:7The7nurse7in7the7intensive7care7unit7must7be7open7to7ever-
changing7situations.7The7nurse7must7be7flexible.
Rationale72:7The7rapid7changes7in7the7intensive7care7unit7do7not7allow7for7extended7time7when7considering7a
ctions.
Rationale73:7A7quiet7and7introverted7nurse7may7not7be7a7good7match7for7the7high7paced7high-
7acuity7care7unit7due7to7the7need7for7teamwork7and7interaction.
Rationale74:7Excitement7about7all7experiences7is7a7beneficial7characteristic7in7healthcare7but7is7not7the7
most7important7factor7for7this7particular7care7unit.
Global7Rationale:
Cognitive7Level:7Analyzing
Client7Need:7Safe7Effective7Care7Environment7Client7Need7Sub:7Management7of7Care
37|7P7a7g7e
, Nursing/Integrated7Concepts:7Nursing7Process:7Assessment7Learning7Outcome:71-2
Question747Type:7MCSA
The7registered7nurse7is7working7as7charge7nurse7on7a7busy7high-
acuity7care7unit.7Unexpectedly,7a7coworker7becomes7ill7and7needs7to7leave.7There7is7a7period7of7time7in
7which7the7unit7is7short7staffed7while7the7ill7coworkers7replacement7travels7in7to7work.7What7action7by7
the7charge7nurse7is7indicated?
1. Make7no7changes7until7the7replacement7nurse7arrives.
2. Assign7the7less7acute7patients7to7be7cared7for7by7the7unlicensed7assistive7personnel.
3. Assign7the7unlicensed7assistive7personnel7to7watch7the7monitors7and7call7for7help7if7a7patient7gets7i
nto7trouble.
4. Contact7the7house7supervisor7and7ask7for7a7float7nurse7to7be7sent7to7the7unit.7Correct7Answer:74
Rationale71:7The7unit7is7understaffed.7Replacement7help7must7be7provided.7It7is7inappropriate7to7wait7f
or7the7replacement7nurse.
Rationale72:7The7unlicensed7assistive7personnel7are7only7able7to7provide7care7under7the7direct7supervisio
n7of7the7nurse.
Rationale73:7Watching7monitors7is7not7within7the7job7description7of7the7unlicensed7assistive7personnel7a
nd7is7not7appropriate.7The7manager7would7be7putting7both7patient7safety7and7the7unlicensed7assistive7pe
rsonnel7at7risk.
Rationale74:7The7manager7should7obtain7help7until7the7replacement7nurse7arrives.7Contacting7the7hous
e7supervisor7and7asking7for7a7temporary7float7nurse7is7the7best7intervention.
Global7Rationale:
Cognitive7Level:7Analyzing
Client7Need:7Safe7Effective7Care7Environment7Client7Need7Sub:7Management7of7Care7Nursing/Integr
ated7Concepts:7Nursing7Process:7Implementation7Learning7Outcome:71-2
Question757Type:7MCSA
A7recent7nursing7school7graduate7reports7having7an7interview7with7a7magnet7hospital.7When7preparing7f
or7the7interview,7the7graduate7nurse7researches7the7concept7of7magnet7status.7Which7perceptions7by7the7
nurse7indicate7an7adequate7understanding?
1. Magnet7status7is7an7accreditation7from7the7National7League7for7Nurses.
2. Magnet7status7facilities7pay7substantial7recruitment7bonuses.
3. Magnet7status7facilities7promote7the7interests7of7professional7nursing.
4. Magnet7status7hospitals7must7establish7nurse-to-patient7ratios.7Correct7Answer:73
47|7P7a7g7e
7 7 7
Acuity Nursing 7th Editio
7 7 7
n
by Kathleen Wagner, Melanie Hardin-
7 7 7 7
7Pierce, Darlene Welsh & Karen Johnson
7 7 7 7 7
All Chapters 1-39 With Rationales| A+ PASS
7 7 7 7 7 7
17|7P7a7g7e
, Chapter71.7High-Acuity7Nursing
Question717T
ype:7MCSA
The7patient7who7had7surgery7yesterday7reports7his7chest7feels7tight.7Assessment7reveals7respiratory7rate7
of729,7inspiratory7wheezes,7stridor,7and7an7oxygenation7saturation7of780%.7The7nurse7would7consider7th
is7patient7to7be7which7priority7for7transfer7to7the7intensive7care7unit7(ICU)?
1. Priority71
2. Priority72
3. Priority73
4. Priority74
Correct7Answer:71
Rationale71:7This7patient7is7exhibiting7signs7of7an7acute7respiratory7event7for7which7intubation7or7othe
r7intensive7treatment7may7be7necessary.7Priority717patients7are7acutely7ill7and7need7intensive7treatment
7and7monitoring7not7provided7outside7of7the7ICU.
Rationale72:7Priority727refers7to7patients7needing7intensive7monitoring7and7may7potentially7need7additional7i
nterventions.7They7are7typically7not7evolving7an7acute7event7as7is7the7case7with7this7patient.
Rationale73:7Priority737patients7are7critically7ill7but7have7little7chance7of7recovery7from7their7illness
es.7Limits7are7placed7on7therapeutic7interventions7and7they7can7be7cared7for7in7areas7other7than7the7
ICU7if7necessary.
Rationale74:7Priority747patients7have7no7signs7or7symptoms7that7indicate7intensive7monitoring7or7treatme
nt7are7necessary.
Global7Rationale:
Cognitive7Level:7Analyzing
Client7Need:7Safe7Effective7Care7Environment7Client7Need7Sub:7Management7of7Care7Nursing/Integra
ted7Concepts:7Nursing7Process:7Planning7Learning7Outcome:71-1
Question727Type:7MCSA
The7daughter7of7a7patient7who7is7dying7questions7the7placement7of7her7father7on7the7medicalsurgical7c
are7unit7(MSCU).7She7requests7he7be7placed7in7the7intensive7care7unit7(ICU)7because7of7concern7her7f
ather7may7not7receive7close7observation7on7a7busy7hospital7unit.7Which7action7is7indicated7by7the7nurs
e?
1. Notify7the7intensive7care7unit7of7an7impending7transfer.
2. Tell7the7daughter7that7her7father7does7not7meet7criteria7for7placement7in7the7more7expensive7ICU.
3. Discuss7the7care7that7can7be7provided7on7the7unit7with7the7family7member.
27|7P7a7g7e
,4. Contact7the7physician.
Correct7Answer:73
Rationale71:7The7nurse7cannot7make7this7transfer7decision7independently.
Rationale72:7Telling7the7daughter7that7her7father7does7not7meet7criteria7for7transfer7is7not7therapeutic.7
Bringing7up7the7issue7of7cost7may7cause7the7daughter7to7offer7to7pay7the7difference7between7the7costs7o
f7the7two7units.7This7would7create7a7serious7ethical7dilemma.
Rationale73:7The7best7initial7response7is7to7help7the7daughter7understand7the7level7of7care7and7observatio
n7that7will7be7provided7on7the7MSCU7so7as7to7help7her7understand7that7her7fathers7care7will7be7a7priorit
y.
Rationale74:7The7nurse7should7try7to7intervene7in7this7situation7before7involving7the7physician.7Global7
Rationale:
Cognitive7Level:7Analyzing
Client7Need:7Safe7Effective7Care7Environment7Client7Need7Sub:7Management7of7Care7Nursing/Integr
ated7Concepts:7Nursing7Process:7Implementation7Learning7Outcome:71-1
Question737Type:7MCSA
A7nurse7who7is7contemplating7taking7a7position7in7an7intensive7care7unit7is7reviewing7her7strengths7an
d7weaknesses.7Which7characteristics7of7the7nurse7will7be7of7the7greatest7benefit7in7the7intensive7care7e
nvironment?
1. Feels7comfortable7in7ever7changing7situations
2. Closely7evaluates7the7pros7and7cons7of7each7decision7for7a7long7period7of7time7before7making7a7decision
3. Is7quiet7and7introverted
4. Is7excited7about7all7new7experiences7Correct7Answer:71
Rationale71:7The7nurse7in7the7intensive7care7unit7must7be7open7to7ever-
changing7situations.7The7nurse7must7be7flexible.
Rationale72:7The7rapid7changes7in7the7intensive7care7unit7do7not7allow7for7extended7time7when7considering7a
ctions.
Rationale73:7A7quiet7and7introverted7nurse7may7not7be7a7good7match7for7the7high7paced7high-
7acuity7care7unit7due7to7the7need7for7teamwork7and7interaction.
Rationale74:7Excitement7about7all7experiences7is7a7beneficial7characteristic7in7healthcare7but7is7not7the7
most7important7factor7for7this7particular7care7unit.
Global7Rationale:
Cognitive7Level:7Analyzing
Client7Need:7Safe7Effective7Care7Environment7Client7Need7Sub:7Management7of7Care
37|7P7a7g7e
, Nursing/Integrated7Concepts:7Nursing7Process:7Assessment7Learning7Outcome:71-2
Question747Type:7MCSA
The7registered7nurse7is7working7as7charge7nurse7on7a7busy7high-
acuity7care7unit.7Unexpectedly,7a7coworker7becomes7ill7and7needs7to7leave.7There7is7a7period7of7time7in
7which7the7unit7is7short7staffed7while7the7ill7coworkers7replacement7travels7in7to7work.7What7action7by7
the7charge7nurse7is7indicated?
1. Make7no7changes7until7the7replacement7nurse7arrives.
2. Assign7the7less7acute7patients7to7be7cared7for7by7the7unlicensed7assistive7personnel.
3. Assign7the7unlicensed7assistive7personnel7to7watch7the7monitors7and7call7for7help7if7a7patient7gets7i
nto7trouble.
4. Contact7the7house7supervisor7and7ask7for7a7float7nurse7to7be7sent7to7the7unit.7Correct7Answer:74
Rationale71:7The7unit7is7understaffed.7Replacement7help7must7be7provided.7It7is7inappropriate7to7wait7f
or7the7replacement7nurse.
Rationale72:7The7unlicensed7assistive7personnel7are7only7able7to7provide7care7under7the7direct7supervisio
n7of7the7nurse.
Rationale73:7Watching7monitors7is7not7within7the7job7description7of7the7unlicensed7assistive7personnel7a
nd7is7not7appropriate.7The7manager7would7be7putting7both7patient7safety7and7the7unlicensed7assistive7pe
rsonnel7at7risk.
Rationale74:7The7manager7should7obtain7help7until7the7replacement7nurse7arrives.7Contacting7the7hous
e7supervisor7and7asking7for7a7temporary7float7nurse7is7the7best7intervention.
Global7Rationale:
Cognitive7Level:7Analyzing
Client7Need:7Safe7Effective7Care7Environment7Client7Need7Sub:7Management7of7Care7Nursing/Integr
ated7Concepts:7Nursing7Process:7Implementation7Learning7Outcome:71-2
Question757Type:7MCSA
A7recent7nursing7school7graduate7reports7having7an7interview7with7a7magnet7hospital.7When7preparing7f
or7the7interview,7the7graduate7nurse7researches7the7concept7of7magnet7status.7Which7perceptions7by7the7
nurse7indicate7an7adequate7understanding?
1. Magnet7status7is7an7accreditation7from7the7National7League7for7Nurses.
2. Magnet7status7facilities7pay7substantial7recruitment7bonuses.
3. Magnet7status7facilities7promote7the7interests7of7professional7nursing.
4. Magnet7status7hospitals7must7establish7nurse-to-patient7ratios.7Correct7Answer:73
47|7P7a7g7e
