1|P a g e
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, Chapter 1. High-Acuity Nursing gy gy gy
Question 1 gy gy
Type: MCSA gy
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate
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yof 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider
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this patient to be which priority for transfer to the intensive care unit (ICU)?
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1. Priority 1 gy
2. Priority 2 gy
3. Priority 3 gy
4. Priority 4 gy
Correct Answer: 1 gy gy
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or ot
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her intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatm
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ent and 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 illne
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sses. Limits are placed on therapeutic interventions and they can be cared for in areas other than t
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he ICU if necessary.
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Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatm
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ent are necessary.
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Global Rationale: gy
Cognitive Level: Analyzing gy gy
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integr
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ated Concepts: Nursing Process: Planning Learning Outcome: 1-1
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Question 2 Type: MCSA gy gy gy
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical
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care unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern h
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er father may not receive close observation on a busy hospital unit. Which action is indicated by th
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e 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 gy gy
.
Correct Answer: 3 gy gy
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
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of the 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 observati
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on that will be provided on the MSCU so as to help her understand that her fathers care will be a pri
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ority.
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 gy gy
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integ
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rated Concepts: Nursing Process: Implementation Learning Outcome: 1-1
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Question 3 Type: MCSA gy gy gy
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths a
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nd weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive car
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e 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-
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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
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actions.
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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 th
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e most important factor for this particular care unit.
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Global Rationale: gy
Cognitive Level: Analyzing gy gy
3|P a g e
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, Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
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4|P a g e
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, Chapter 1. High-Acuity Nursing gy gy gy
Question 1 gy gy
Type: MCSA gy
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate
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yof 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider
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this patient to be which priority for transfer to the intensive care unit (ICU)?
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1. Priority 1 gy
2. Priority 2 gy
3. Priority 3 gy
4. Priority 4 gy
Correct Answer: 1 gy gy
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or ot
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her intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatm
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ent and 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 illne
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sses. Limits are placed on therapeutic interventions and they can be cared for in areas other than t
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he ICU if necessary.
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Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatm
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ent are necessary.
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Global Rationale: gy
Cognitive Level: Analyzing gy gy
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integr
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ated Concepts: Nursing Process: Planning Learning Outcome: 1-1
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Question 2 Type: MCSA gy gy gy
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical
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care unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern h
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er father may not receive close observation on a busy hospital unit. Which action is indicated by th
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e nurse?
gy
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 gy gy
.
Correct Answer: 3 gy gy
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
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of the 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 observati
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on that will be provided on the MSCU so as to help her understand that her fathers care will be a pri
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ority.
Rationale 4: The nurse should try to intervene in this situation before involving the physician. Global
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Rationale:
y
Cognitive Level: Analyzing gy gy
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integ
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rated Concepts: Nursing Process: Implementation Learning Outcome: 1-1
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Question 3 Type: MCSA gy gy gy
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths a
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nd weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive car
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e environment?
gy
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
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actions.
y
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 th
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e most important factor for this particular care unit.
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Global Rationale: gy
Cognitive Level: Analyzing gy gy
3|P a g e
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, Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
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4|P a g e
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