1|P a g e
zl zl zl zl zl
, Chapter 1. High-Acuity Nursing zl zl zl
Question 1 T zl zl
ype: MCSA zl
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate of 29,
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl z
inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this patient t
l zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
o be which priority for transfer to the intensive care unit (ICU)?
zl zl zl zl zl zl zl zl zl zl zl
1. Priority 1 zl
2. Priority 2 zl
3. Priority 3 zl
4. Priority 4 zl
Correct Answer: 1 zl zl
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other inte
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
nsive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment and monit
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
oring not provided outside of the ICU.
zl zl zl zl zl zl
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additional interv
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
entions. They are typically not evolving an acute event as is the case with this patient.
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their illnesses. Li
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
mits are placed on therapeutic interventions and they can be cared for in areas other than the ICU if nece
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
ssary.
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment are
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl z
necessary.
l
Global Rationale: zl
Cognitive Level: Analyzing zl zl
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated
zl zl zl zl zl zl zl zl zl zl zl zl zl
Concepts: Nursing Process: Planning Learning Outcome: 1-1
zl zl zl zl zl zl
Question 2 Type: MCSA zl zl zl
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care un
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
it (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father may n
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
ot receive close observation on a busy hospital unit. Which action is indicated by the nurse?
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
1. Notify the intensive care unit of an impending transfer.
zl zl zl zl zl zl zl zl
2. Tell the daughter that her father does not meet criteria for placement in the more expensive ICU.
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
3. Discuss the care that can be provided on the unit with the family member.
zl zl zl zl zl zl zl zl zl zl zl zl zl
2|P a g e
zl zl zl zl zl
,4. Contact the physician. zl zl
Correct Answer: 3 zl zl
Rationale 1: The nurse cannot make this transfer decision independently.
zl zl zl zl zl zl zl zl zl
Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not therapeutic. Bringi
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
ng up the issue of cost may cause the daughter to offer to pay the difference between the costs of the two unit
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
s. This would create a serious ethical dilemma.
zl zl zl zl zl zl zl
Rationale 3: The best initial response is to help the daughter understand the level of care and observation that
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
will be provided on the MSCU so as to help her understand that her fathers care will be a priority.
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
Rationale 4: The nurse should try to intervene in this situation before involving the physician. Global Ration
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
ale:
Cognitive Level: Analyzing zl zl
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated
zl zl zl zl zl zl zl zl zl zl zl zl
Concepts: Nursing Process: Implementation Learning Outcome: 1-1
zl zl zl zl zl zl zl
Question 3 Type: MCSA zl zl zl
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and wea
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
knesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care environmen
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
t?
1. Feels comfortable in ever changing situations
zl zl zl zl zl
2. Closely evaluates the pros and cons of each decision for a long period of time before making a decision
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
3. Is quiet and introverted
zl zl zl
4. Is excited about all new experiences Correct Answer: 1
zl zl zl zl zl zl zl zl
Rationale 1: The nurse in the intensive care unit must be open to ever-
zl zl zl zl zl zl zl zl zl zl zl zl zl
changing situations. The nurse must be flexible. zl zl zl zl zl zl
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when considering actions
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
.
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
acuity care unit due to the need for teamwork and interaction.
zl zl zl zl zl zl zl zl zl zl zl
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the most
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
important factor for this particular care unit. zl zl zl zl zl zl
Global Rationale: zl
Cognitive Level: Analyzing zl zl
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
zl zl zl zl zl zl zl zl zl zl zl
3|P a g e
zl zl zl zl zl
, Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 zl zl zl zl zl zl zl
Question 4 Type: MCSA zl zl zl
The registered nurse is working as charge nurse on a busy high-
zl zl zl zl zl zl zl zl zl zl zl
acuity care unit. Unexpectedly, a coworker becomes ill and needs to leave. There is a period of time in whic
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
h the unit is short staffed while the ill coworkers replacement travels in to work. What action by the charge
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
nurse is indicated? zl zl
1. Make no changes until the replacement nurse arrives. zl zl zl zl zl zl zl
2. Assign the less acute patients to be cared for by the unlicensed assistive personnel.
zl zl zl zl zl zl zl zl zl zl zl zl zl
3. Assign the unlicensed assistive personnel to watch the monitors and call for help if a patient gets into tro
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
uble.
4. Contact the house supervisor and ask for a float nurse to be sent to the unit. Correct Answer: 4
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
Rationale 1: The unit is understaffed. Replacement help must be provided. It is inappropriate to wait for the
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
replacement nurse.
zl zl
Rationale 2: The unlicensed assistive personnel are only able to provide care under the direct supervision of t
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
he nurse. zl
Rationale 3: Watching monitors is not within the job description of the unlicensed assistive personnel and is
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
not appropriate. The manager would be putting both patient safety and the unlicensed assistive personnel at
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
risk.
Rationale 4: The manager should obtain help until the replacement nurse arrives. Contacting the house sup
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
ervisor and asking for a temporary float nurse is the best intervention.
zl zl zl zl zl zl zl zl zl zl zl
Global Rationale: zl
Cognitive Level: Analyzing zl zl
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated
zl zl zl zl zl zl zl zl zl zl zl zl
Concepts: Nursing Process: Implementation Learning Outcome: 1-2
zl zl zl zl zl zl zl
Question 5 Type: MCSA zl zl zl
A recent nursing school graduate reports having an interview with a magnet hospital. When preparing for th
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
e interview, the graduate nurse researches the concept of magnet status. Which perceptions by the nurse indi
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
cate an adequate understanding?
zl zl zl
1. Magnet status is an accreditation from the National League for Nurses.
zl zl zl zl zl zl zl zl zl zl
2. Magnet status facilities pay substantial recruitment bonuses. zl zl zl zl zl zl
3. Magnet status facilities promote the interests of professional nursing.
zl zl zl zl zl zl zl zl
4. Magnet status hospitals must establish nurse-to-patient ratios. Correct Answer: 3
zl zl zl zl zl zl zl zl zl
4|P a g e
zl zl zl zl zl
zl zl zl zl zl
, Chapter 1. High-Acuity Nursing zl zl zl
Question 1 T zl zl
ype: MCSA zl
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate of 29,
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl z
inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this patient t
l zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
o be which priority for transfer to the intensive care unit (ICU)?
zl zl zl zl zl zl zl zl zl zl zl
1. Priority 1 zl
2. Priority 2 zl
3. Priority 3 zl
4. Priority 4 zl
Correct Answer: 1 zl zl
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or other inte
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
nsive treatment may be necessary. Priority 1 patients are acutely ill and need intensive treatment and monit
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
oring not provided outside of the ICU.
zl zl zl zl zl zl
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additional interv
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
entions. They are typically not evolving an acute event as is the case with this patient.
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their illnesses. Li
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
mits are placed on therapeutic interventions and they can be cared for in areas other than the ICU if nece
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
ssary.
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment are
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl z
necessary.
l
Global Rationale: zl
Cognitive Level: Analyzing zl zl
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated
zl zl zl zl zl zl zl zl zl zl zl zl zl
Concepts: Nursing Process: Planning Learning Outcome: 1-1
zl zl zl zl zl zl
Question 2 Type: MCSA zl zl zl
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care un
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
it (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father may n
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
ot receive close observation on a busy hospital unit. Which action is indicated by the nurse?
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
1. Notify the intensive care unit of an impending transfer.
zl zl zl zl zl zl zl zl
2. Tell the daughter that her father does not meet criteria for placement in the more expensive ICU.
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
3. Discuss the care that can be provided on the unit with the family member.
zl zl zl zl zl zl zl zl zl zl zl zl zl
2|P a g e
zl zl zl zl zl
,4. Contact the physician. zl zl
Correct Answer: 3 zl zl
Rationale 1: The nurse cannot make this transfer decision independently.
zl zl zl zl zl zl zl zl zl
Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not therapeutic. Bringi
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
ng up the issue of cost may cause the daughter to offer to pay the difference between the costs of the two unit
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
s. This would create a serious ethical dilemma.
zl zl zl zl zl zl zl
Rationale 3: The best initial response is to help the daughter understand the level of care and observation that
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
will be provided on the MSCU so as to help her understand that her fathers care will be a priority.
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
Rationale 4: The nurse should try to intervene in this situation before involving the physician. Global Ration
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
ale:
Cognitive Level: Analyzing zl zl
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated
zl zl zl zl zl zl zl zl zl zl zl zl
Concepts: Nursing Process: Implementation Learning Outcome: 1-1
zl zl zl zl zl zl zl
Question 3 Type: MCSA zl zl zl
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and wea
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
knesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care environmen
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
t?
1. Feels comfortable in ever changing situations
zl zl zl zl zl
2. Closely evaluates the pros and cons of each decision for a long period of time before making a decision
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
3. Is quiet and introverted
zl zl zl
4. Is excited about all new experiences Correct Answer: 1
zl zl zl zl zl zl zl zl
Rationale 1: The nurse in the intensive care unit must be open to ever-
zl zl zl zl zl zl zl zl zl zl zl zl zl
changing situations. The nurse must be flexible. zl zl zl zl zl zl
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when considering actions
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
.
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
acuity care unit due to the need for teamwork and interaction.
zl zl zl zl zl zl zl zl zl zl zl
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the most
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
important factor for this particular care unit. zl zl zl zl zl zl
Global Rationale: zl
Cognitive Level: Analyzing zl zl
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
zl zl zl zl zl zl zl zl zl zl zl
3|P a g e
zl zl zl zl zl
, Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 zl zl zl zl zl zl zl
Question 4 Type: MCSA zl zl zl
The registered nurse is working as charge nurse on a busy high-
zl zl zl zl zl zl zl zl zl zl zl
acuity care unit. Unexpectedly, a coworker becomes ill and needs to leave. There is a period of time in whic
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
h the unit is short staffed while the ill coworkers replacement travels in to work. What action by the charge
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
nurse is indicated? zl zl
1. Make no changes until the replacement nurse arrives. zl zl zl zl zl zl zl
2. Assign the less acute patients to be cared for by the unlicensed assistive personnel.
zl zl zl zl zl zl zl zl zl zl zl zl zl
3. Assign the unlicensed assistive personnel to watch the monitors and call for help if a patient gets into tro
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
uble.
4. Contact the house supervisor and ask for a float nurse to be sent to the unit. Correct Answer: 4
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
Rationale 1: The unit is understaffed. Replacement help must be provided. It is inappropriate to wait for the
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
replacement nurse.
zl zl
Rationale 2: The unlicensed assistive personnel are only able to provide care under the direct supervision of t
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
he nurse. zl
Rationale 3: Watching monitors is not within the job description of the unlicensed assistive personnel and is
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
not appropriate. The manager would be putting both patient safety and the unlicensed assistive personnel at
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
risk.
Rationale 4: The manager should obtain help until the replacement nurse arrives. Contacting the house sup
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
ervisor and asking for a temporary float nurse is the best intervention.
zl zl zl zl zl zl zl zl zl zl zl
Global Rationale: zl
Cognitive Level: Analyzing zl zl
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care Nursing/Integrated
zl zl zl zl zl zl zl zl zl zl zl zl
Concepts: Nursing Process: Implementation Learning Outcome: 1-2
zl zl zl zl zl zl zl
Question 5 Type: MCSA zl zl zl
A recent nursing school graduate reports having an interview with a magnet hospital. When preparing for th
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
e interview, the graduate nurse researches the concept of magnet status. Which perceptions by the nurse indi
zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl zl
cate an adequate understanding?
zl zl zl
1. Magnet status is an accreditation from the National League for Nurses.
zl zl zl zl zl zl zl zl zl zl
2. Magnet status facilities pay substantial recruitment bonuses. zl zl zl zl zl zl
3. Magnet status facilities promote the interests of professional nursing.
zl zl zl zl zl zl zl zl
4. Magnet status hospitals must establish nurse-to-patient ratios. Correct Answer: 3
zl zl zl zl zl zl zl zl zl
4|P a g e
zl zl zl zl zl
