TEST BANK
HIGH-ACUITY NURSING 7TH EDITION
BY KATHLEEN WAGNER, MELANIE HARDIN- PIERCE,
DARLENE WELSH & KAREN JOHNSON
All Chapters 1-39 With Rationales| A+ PASS
1|P age
,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
2|P age
,Outcome: 1-1
Question 2 Type: MCSA
The daughter of a patient who is dying questions the placement of her father on
the medical surgical 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. Contactthe
physician.
Correct Answer: 3
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
3|P age
, 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
The registered nurse is working as charge nurse on a busy high-acuity care unit.
Unexpectedly, a coworker becomes ill and needs to leave. There is a period of
time in which the unit is short staffed while the ill coworkers replacement travels
in to work. What action by the charge nurse is indicated?
1. Make no changes until the replacement nurse arrives.
2. Assign the less acute patients to be cared for by the unlicensed assistive personnel.
3. Assign the unlicensed assistive personnel to watch the monitors and call for
help if a patient gets into trouble.
4|P age
HIGH-ACUITY NURSING 7TH EDITION
BY KATHLEEN WAGNER, MELANIE HARDIN- PIERCE,
DARLENE WELSH & KAREN JOHNSON
All Chapters 1-39 With Rationales| A+ PASS
1|P age
,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
2|P age
,Outcome: 1-1
Question 2 Type: MCSA
The daughter of a patient who is dying questions the placement of her father on
the medical surgical 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. Contactthe
physician.
Correct Answer: 3
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
3|P age
, 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
The registered nurse is working as charge nurse on a busy high-acuity care unit.
Unexpectedly, a coworker becomes ill and needs to leave. There is a period of
time in which the unit is short staffed while the ill coworkers replacement travels
in to work. What action by the charge nurse is indicated?
1. Make no changes until the replacement nurse arrives.
2. Assign the less acute patients to be cared for by the unlicensed assistive personnel.
3. Assign the unlicensed assistive personnel to watch the monitors and call for
help if a patient gets into trouble.
4|P age
