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, Chapter 1. High-Acuity Nursing
AQ AQ AQ
Question 1 AQ AQ
Type: MCS AQ
A
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respirator
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y rate of 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse wou
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
ld consider this patient to be which priority for transfer to the intensive care unit (ICU)?
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
1. Priority 1 AQ
2. Priority 2 AQ
3. Priority 3 AQ
4. Priority 4 AQ
Correct Answer: 1 AQ AQ
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ A
Qor other intensive treatment may be necessary. Priority 1 patients are acutely ill and need inte
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
nsive treatment and monitoring not provided outside of the ICU.
AQ AQ AQ AQ AQ AQ AQ AQ AQ
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additi
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
onal interventions. They are typically not evolving an acute event as is the case with this patient.
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
illnesses. Limits are placed on therapeutic interventions and they can be cared for in areas
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other than the ICU if necessary.
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Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or t
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reatment are necessary. AQ AQ
Global Rationale: AQ
Cognitive Level: Analyzing AQ AQ
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/I
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
ntegrated Concepts: Nursing Process: Planning Learning Outcome: 1-1
AQ AQ AQ AQ AQ AQ AQ
Question 2 Type: MCSA AQ AQ AQ
The daughter of a patient who is dying questions the placement of her father on the medicalsu
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
rgical care unit (MSCU). She requests he be placed in the intensive care unit (ICU) because
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
of concern her father may not receive close observation on a busy hospital unit. Which action
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
is indicated by the nurse?
AQ AQ AQ AQ AQ
1. Notify the intensive care unit of an impending transfer.
AQ AQ AQ AQ AQ AQ AQ AQ
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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, 4. Contact the physicia AQ AQ
n.
Correct Answer: 3 AQ AQ
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 thera
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
peutic. Bringing up the issue of cost may cause the daughter to offer to pay the difference bet
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
ween the costs of the two units. This would create a serious ethical dilemma.
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
Rationale 3: The best initial response is to help the daughter understand the level of care and ob
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
servation that will be provided on the MSCU so as to help her understand that her fathers care
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
will be a priority.
AQ AQ AQ AQ
Rationale 4: The nurse should try to intervene in this situation before involving the physician.
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
Global Rationale: AQ
Cognitive Level: Analyzing AQ AQ
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-1
AQ AQ AQ AQ AQ AQ AQ
Question 3 Type: MCSA AQ AQ AQ
A nurse who is contemplating taking a position in an intensive care unit is reviewing her stren
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
gths and weaknesses. Which characteristics of the nurse will be of the greatest benefit in the
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
intensive care environment?
AQ AQ
1. Feels comfortable in ever changing situations
AQ AQ AQ AQ AQ
2. Closely evaluates the pros and cons of each decision for a long period of time before making a d
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
ecision
3. Is quiet and introverted
AQ AQ AQ
4. Is excited about all new experiences Correct Answer: 1
AQ AQ AQ AQ AQ AQ AQ AQ
Rationale 1: The nurse in the intensive care unit must be open to ever-
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
changing situations. The nurse must be flexible.
AQ AQ AQ AQ AQ AQ
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when consi
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
dering actions. AQ
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
acuity care unit due to the need for teamwork and interaction.
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
not the most important factor for this particular care unit.
AQ AQ AQ AQ AQ AQ AQ AQ AQ
Global Rationale: AQ
Cognitive Level: Analyzing AQ AQ
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, Chapter 1. High-Acuity Nursing
AQ AQ AQ
Question 1 AQ AQ
Type: MCS AQ
A
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respirator
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
y rate of 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse wou
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
ld consider this patient to be which priority for transfer to the intensive care unit (ICU)?
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
1. Priority 1 AQ
2. Priority 2 AQ
3. Priority 3 AQ
4. Priority 4 AQ
Correct Answer: 1 AQ AQ
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ A
Qor other intensive treatment may be necessary. Priority 1 patients are acutely ill and need inte
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
nsive treatment and monitoring not provided outside of the ICU.
AQ AQ AQ AQ AQ AQ AQ AQ AQ
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additi
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
onal interventions. They are typically not evolving an acute event as is the case with this patient.
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
illnesses. Limits are placed on therapeutic interventions and they can be cared for in areas
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
other than the ICU if necessary.
AQ AQ AQ AQ AQ
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or t
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
reatment are necessary. AQ AQ
Global Rationale: AQ
Cognitive Level: Analyzing AQ AQ
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/I
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
ntegrated Concepts: Nursing Process: Planning Learning Outcome: 1-1
AQ AQ AQ AQ AQ AQ AQ
Question 2 Type: MCSA AQ AQ AQ
The daughter of a patient who is dying questions the placement of her father on the medicalsu
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
rgical care unit (MSCU). She requests he be placed in the intensive care unit (ICU) because
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
of concern her father may not receive close observation on a busy hospital unit. Which action
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
is indicated by the nurse?
AQ AQ AQ AQ AQ
1. Notify the intensive care unit of an impending transfer.
AQ AQ AQ AQ AQ AQ AQ AQ
2. Tell the daughter that her father does not meet criteria for placement in the more expensive ICU.
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
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e
,3. Discuss the care that can be provided on the unit with the family member.
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
3
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e
, 4. Contact the physicia AQ AQ
n.
Correct Answer: 3 AQ AQ
Rationale 1: The nurse cannot make this transfer decision independently.
AQ AQ AQ AQ AQ AQ AQ AQ AQ
Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not thera
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
peutic. Bringing up the issue of cost may cause the daughter to offer to pay the difference bet
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
ween the costs of the two units. This would create a serious ethical dilemma.
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
Rationale 3: The best initial response is to help the daughter understand the level of care and ob
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
servation that will be provided on the MSCU so as to help her understand that her fathers care
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
will be a priority.
AQ AQ AQ AQ
Rationale 4: The nurse should try to intervene in this situation before involving the physician.
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
Global Rationale: AQ
Cognitive Level: Analyzing AQ AQ
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-1
AQ AQ AQ AQ AQ AQ AQ
Question 3 Type: MCSA AQ AQ AQ
A nurse who is contemplating taking a position in an intensive care unit is reviewing her stren
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
gths and weaknesses. Which characteristics of the nurse will be of the greatest benefit in the
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
intensive care environment?
AQ AQ
1. Feels comfortable in ever changing situations
AQ AQ AQ AQ AQ
2. Closely evaluates the pros and cons of each decision for a long period of time before making a d
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
ecision
3. Is quiet and introverted
AQ AQ AQ
4. Is excited about all new experiences Correct Answer: 1
AQ AQ AQ AQ AQ AQ AQ AQ
Rationale 1: The nurse in the intensive care unit must be open to ever-
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
changing situations. The nurse must be flexible.
AQ AQ AQ AQ AQ AQ
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when consi
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
dering actions. AQ
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
acuity care unit due to the need for teamwork and interaction.
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is
AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ AQ
not the most important factor for this particular care unit.
AQ AQ AQ AQ AQ AQ AQ AQ AQ
Global Rationale: AQ
Cognitive Level: Analyzing AQ AQ
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