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Test bank for High Acuity Nursing 7th Edition
By Wagner Pierce Welsh
All chapters (1-39) |Q&A Verified with Rationales |Graded A+
ISBN 9780134459295
~1~
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TABLE OF CONTENTS
Chapter 1. High-Acuity Nursing Question 1 .................................................................................................. 3
Chapter 2. Holistic Care of the Patient and Family Question 1 ................................................................... 16
Chapter 3. Palliative and End-of-life Care ................................................................................................... 29
Chapter 4. The Older Adult High-Acuity Patient ......................................................................................... 37
Chapter 5. Acute Pain Management ............................................................................................................ 49
Chapter 6. Nutrition Support ...................................................................................................................... 62
Chapter 7. Mechanical Ventilation .............................................................................................................. 74
Chapter 8. Basic Hemodynamic Monitoring ............................................................................................... 86
Chapter 9. Basic Cardiac Rhythm Monitoring ............................................................................................. 98
Chapter 10. Complex Wound Management ............................................................................................... 110
Chapter 11. Determinants and Assessment of Pulmonary Function........................................................ 122
Chapter 12. Alterations in Pulmonary Function ....................................................................................... 134
Chapter 13. Determinants and Assessment of Cardiac Function ............................................................. 146
Chapter 14. Alterations in Cardiac Function ............................................................................................. 159
Chapter 15. Alterations in Myocardial Tissue Perfusion .......................................................................... 171
Chapter 16. Determinants and Assessment of Cerebral Function ............................................................ 183
Chapter 17. Mentation and Sensory Motor Complications of Acute Illness ............................................. 195
Chapter 18. Acute Stroke Injury ................................................................................................................ 206
Chapter 19. Traumatic Brain Injury .......................................................................................................... 219
Chapter 20. Acute Spinal Cord Injury ........................................................................................................ 231
Chapter 21. Determinants and Assessment of Gastrointestinal Function ............................................... 243
Chapter 22. Alterations in Gastrointestinal Function ............................................................................... 255
Chapter 23. Alterations in Liver Function ................................................................................................. 267
Chapter 24. Alterations in Pancreatic Function ........................................................................................ 279
Chapter 25. Determinants and Assessment of Fluid and Electrolyte Balance ......................................... 291
Chapter 26. Alterations in Fluid and Electrolyte Balance ......................................................................... 302
Chapter 27. Alterations in Kidney Function.............................................................................................. 314
Chapter 28. Determinants and Assessment of Hematologic Function ..................................................... 327
Chapter 29. Alterations in Red Blood Cell Function and Hemostasis ....................................................... 339
Chapter 30. Alterations in White Blood Cell Function and Oncologic Emergencies ................................ 350
Chapter 31. Determinants and Assessment of Nutrition and Metabolic Function ................................... 362
Chapter 32. Metabolic Response to Stress ................................................................................................ 374
Chapter 33. Diabetic Crises ....................................................................................................................... 385
Chapter 34. Determinants and Assessment of Oxygenation .................................................................... 397
Chapter 35. Multiple Trauma .................................................................................................................... 409
Chapter 36. Acute Burn Injury .................................................................................................................. 421
Chapter 37. Shock States ........................................................................................................................... 434
Chapter 38. Multiple Organ Dysfunction Syndrome ................................................................................. 445
Chapter 39. Solid Organ and Hematopoietic Stem Cell Transplantation ................................................. 457
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Chapter 1. High-Acuity Nursing Question 1
Type: MCSA
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals
respiratory rate of 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The
nurse would consider this patient to be which priority for transfer to the intensive care unit
(ICU)?
1. Priority 1
2. Priority 2
3. Priority 3
4. Priority 4
CORRECT ANSWER: 1
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or
other intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive
treatment and monitoring not provided outside of the ICU.
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need
additional interventions. They are typically not evolving an acute event as is the case with this
patient.
Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their
illnesses. Limits are placed on therapeutic interventions and they can be cared for in areas other
than the ICU if necessary.
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or
treatment are necessary.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-1
Question 2 Type: MCSA
The daughter of a patient who is dying questions the placement of her father on the
medicalsurgical care unit (MSCU). She requests he be placed in the intensive care unit (ICU)
because of concern her father may not receive close observation on a busy hospital unit. Which
action is indicated by the nurse?
1. Notify the intensive care unit of an impending transfer.
2. Tell the daughter that her father does not meet criteria for placement in the more
expensive ICU.
3. Discuss the care that can be provided on the unit with the family member.
4. Contact the physician.
CORRECT ANSWER: 3
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Rationale 1: The nurse cannot make this transfer decision independently.
Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not
therapeutic. Bringing up the issue of cost may cause the daughter to offer to pay the difference
between the costs of the two units. This would create a serious ethical dilemma.
Rationale 3: The best initial response is to help the daughter understand the level of care and
observation that will be provided on the MSCU so as to help her understand that her fathers care
will be a priority.
Rationale 4: The nurse should try to intervene in this situation before involving the physician.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-1
Question 3 Type: MCSA
A nurse who is contemplating taking a position in an intensive care unit is reviewing her
strengths and weaknesses. Which characteristics of the nurse will be of the greatest benefit in
the intensive care environment?
1. Feels comfortable in ever changing situations
2. Closely evaluates the pros and cons of each decision for a long period of time before
making a decision
3. Is quiet and introverted
4. Is excited about all new experiences
CORRECT ANSWER: 1
Rationale 1: The nurse in the intensive care unit must be open to ever-changing situations. The
nurse must be flexible.
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when
considering actions.
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-
acuity care unit due to the need for teamwork and interaction.
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is
not the most important factor for this particular care unit.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2
Question 4 Type: MCSA
~4~
Test bank for High Acuity Nursing 7th Edition
By Wagner Pierce Welsh
All chapters (1-39) |Q&A Verified with Rationales |Graded A+
ISBN 9780134459295
~1~
,THIS DOCUMENT BELONGS TO TESTBANKSPROF
TABLE OF CONTENTS
Chapter 1. High-Acuity Nursing Question 1 .................................................................................................. 3
Chapter 2. Holistic Care of the Patient and Family Question 1 ................................................................... 16
Chapter 3. Palliative and End-of-life Care ................................................................................................... 29
Chapter 4. The Older Adult High-Acuity Patient ......................................................................................... 37
Chapter 5. Acute Pain Management ............................................................................................................ 49
Chapter 6. Nutrition Support ...................................................................................................................... 62
Chapter 7. Mechanical Ventilation .............................................................................................................. 74
Chapter 8. Basic Hemodynamic Monitoring ............................................................................................... 86
Chapter 9. Basic Cardiac Rhythm Monitoring ............................................................................................. 98
Chapter 10. Complex Wound Management ............................................................................................... 110
Chapter 11. Determinants and Assessment of Pulmonary Function........................................................ 122
Chapter 12. Alterations in Pulmonary Function ....................................................................................... 134
Chapter 13. Determinants and Assessment of Cardiac Function ............................................................. 146
Chapter 14. Alterations in Cardiac Function ............................................................................................. 159
Chapter 15. Alterations in Myocardial Tissue Perfusion .......................................................................... 171
Chapter 16. Determinants and Assessment of Cerebral Function ............................................................ 183
Chapter 17. Mentation and Sensory Motor Complications of Acute Illness ............................................. 195
Chapter 18. Acute Stroke Injury ................................................................................................................ 206
Chapter 19. Traumatic Brain Injury .......................................................................................................... 219
Chapter 20. Acute Spinal Cord Injury ........................................................................................................ 231
Chapter 21. Determinants and Assessment of Gastrointestinal Function ............................................... 243
Chapter 22. Alterations in Gastrointestinal Function ............................................................................... 255
Chapter 23. Alterations in Liver Function ................................................................................................. 267
Chapter 24. Alterations in Pancreatic Function ........................................................................................ 279
Chapter 25. Determinants and Assessment of Fluid and Electrolyte Balance ......................................... 291
Chapter 26. Alterations in Fluid and Electrolyte Balance ......................................................................... 302
Chapter 27. Alterations in Kidney Function.............................................................................................. 314
Chapter 28. Determinants and Assessment of Hematologic Function ..................................................... 327
Chapter 29. Alterations in Red Blood Cell Function and Hemostasis ....................................................... 339
Chapter 30. Alterations in White Blood Cell Function and Oncologic Emergencies ................................ 350
Chapter 31. Determinants and Assessment of Nutrition and Metabolic Function ................................... 362
Chapter 32. Metabolic Response to Stress ................................................................................................ 374
Chapter 33. Diabetic Crises ....................................................................................................................... 385
Chapter 34. Determinants and Assessment of Oxygenation .................................................................... 397
Chapter 35. Multiple Trauma .................................................................................................................... 409
Chapter 36. Acute Burn Injury .................................................................................................................. 421
Chapter 37. Shock States ........................................................................................................................... 434
Chapter 38. Multiple Organ Dysfunction Syndrome ................................................................................. 445
Chapter 39. Solid Organ and Hematopoietic Stem Cell Transplantation ................................................. 457
~2~
, THIS DOCUMENT BELONGS TO TESTBANKSPROF
Chapter 1. High-Acuity Nursing Question 1
Type: MCSA
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals
respiratory rate of 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The
nurse would consider this patient to be which priority for transfer to the intensive care unit
(ICU)?
1. Priority 1
2. Priority 2
3. Priority 3
4. Priority 4
CORRECT ANSWER: 1
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or
other intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive
treatment and monitoring not provided outside of the ICU.
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need
additional interventions. They are typically not evolving an acute event as is the case with this
patient.
Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their
illnesses. Limits are placed on therapeutic interventions and they can be cared for in areas other
than the ICU if necessary.
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or
treatment are necessary.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-1
Question 2 Type: MCSA
The daughter of a patient who is dying questions the placement of her father on the
medicalsurgical care unit (MSCU). She requests he be placed in the intensive care unit (ICU)
because of concern her father may not receive close observation on a busy hospital unit. Which
action is indicated by the nurse?
1. Notify the intensive care unit of an impending transfer.
2. Tell the daughter that her father does not meet criteria for placement in the more
expensive ICU.
3. Discuss the care that can be provided on the unit with the family member.
4. Contact the physician.
CORRECT ANSWER: 3
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Rationale 1: The nurse cannot make this transfer decision independently.
Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not
therapeutic. Bringing up the issue of cost may cause the daughter to offer to pay the difference
between the costs of the two units. This would create a serious ethical dilemma.
Rationale 3: The best initial response is to help the daughter understand the level of care and
observation that will be provided on the MSCU so as to help her understand that her fathers care
will be a priority.
Rationale 4: The nurse should try to intervene in this situation before involving the physician.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-1
Question 3 Type: MCSA
A nurse who is contemplating taking a position in an intensive care unit is reviewing her
strengths and weaknesses. Which characteristics of the nurse will be of the greatest benefit in
the intensive care environment?
1. Feels comfortable in ever changing situations
2. Closely evaluates the pros and cons of each decision for a long period of time before
making a decision
3. Is quiet and introverted
4. Is excited about all new experiences
CORRECT ANSWER: 1
Rationale 1: The nurse in the intensive care unit must be open to ever-changing situations. The
nurse must be flexible.
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when
considering actions.
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-
acuity care unit due to the need for teamwork and interaction.
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is
not the most important factor for this particular care unit.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2
Question 4 Type: MCSA
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