Test Bank for High-Acuity Nursing 7th
v v v v v
Edition
v
byKathleenWagner, MelanieHardin-
Pierce,DarleneWelsh&KarenJohnson
All Chapters 1-39 With Rationales| A+ PASS
v v v v v v
1|P a g
v v v v
e
v
, Chapter 1. High-Acuity Nursing v v v
Question 1 v
v Type:
v MCSA
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate of
v v v v v v v v v v v v v v v
29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this
v v v v v v v v v v v v v v v
patient to be which priority for transfer to the intensive care unit (ICU)?
v v v v v v v v v v v v v
1. Priority 1 v
2. Priority 2 v
3. Priority 3 v
4. Priority 4 v
Correct Answer: 1 v v
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or
v v v v v v v v v v v v v v v
other intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive
v v v v v v v v v v v v v v v
treatment and monitoring not provided outside of the ICU.
v v v v v v v v v
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additional
v v v v v v v v v v v v v v
interventions. They are typically not evolving an acute event as is the case with this patient.
v v v v v v v v v v v v v v v v
Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their
v v v v v v v v v v v v v v v
illnesses. Limits are placed on therapeutic interventions and they can be cared for in areas other
v v v v v v v v v v v v v v v v
than the ICU if necessary.
v v v v v
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment
v v v v v v v v v v v v v v v
are necessary.
v v
Global Rationale: v
Cognitive Level: Analyzing v v
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
v v v v v v v v v v v
v Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-1 v v v v v v v
Question 2 Type: MCSA v v v
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care
v v v v v v v v v v v v v v v v v
unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father
v v v v v v v v v v v v v v v v v v
may not receive close observation on a busy hospital unit. Which action is indicated by the nurse?
v v v v v v v v v v v v v v v v v
1. Notify the intensive care unit of an impending transfer.
v v v v v v v v
2. Tell the daughter that her father does not meet criteria for placement in the more expensive ICU.
v v v v v v v v v v v v v v v v
3. Discuss the care that can be provided on the unit with the family member.
v v v v v v v v v v v v v
2|P a g v v v v
ve
,4. Contact the physician. v v
Correct Answer: 3
v v v
Rationale 1: The nurse cannot make this transfer decision independently.
v v v v v v v v v
Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not therapeutic.
v v v v v v v v v v v v v v v v
vBringing up the issue of cost may cause the daughter to offer to pay the difference between the costs of
v v v v v v v v v v v v v v v v v v v
vthe two units. This would create a serious ethical dilemma.
v v v v v v v v v
Rationale 3: The best initial response is to help the daughter understand the level of care and observation
v v v v v v v v v v v v v v v v v
vthat will be provided on the MSCU so as to help her understand that her fathers care will be a priority.
v v v v v v v v v v v v v v v v v v v v
Rationale 4: The nurse should try to intervene in this situation before involving the physician. Global
v v v v v v v v v v v v v v v
vRationale:
Cognitive Level: Analyzing v v
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
v v v v v v v v v v v
v Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-1 v v v v v v v
Question 3 Type: MCSA v v v
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and
v v v v v v v v v v v v v v v v v
weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care
v v v v v v v v v v v v v v v v
environment?
v
1. Feels comfortable in ever changing situations
v v v v v
2. Closely evaluates the pros and cons of each decision for a long period of time before making a decision
v v v v v v v v v v v v v v v v v v
3. Is quiet and introverted
v v v
4. Is excited about all new experiences Correct Answer: 1
v v v v v v v v
Rationale 1: The nurse in the intensive care unit must be open to ever-changing situations. The nurse must
v v v v v v v v v v v v v v v v v
vbe flexible. v
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when considering
v v v v v v v v v v v v v v v v v
vactions.
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high- acuity
v v v v v v v v v v v v v v v v v v
care unit due to the need for teamwork and interaction.
v v v v v v v v v v
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the
v v v v v v v v v v v v v v v
most important factor for this particular care unit.
v v v v v v v v
Global Rationale: v
Cognitive Level: Analyzing v v
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
v v v v v v v v v v v
3|P a g e
v v v v v
, Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 v v v v v v v
Question 4 Type: MCSA v v v
The registered nurse is working as charge nurse on a busy high-acuity care unit. Unexpectedly, a
v v v v v v v v v v v v v v v
vcoworker becomes ill and needs to leave. There is a period of time in which the unit is short staffed
v v v v v v v v v v v v v v v v v v v
vwhile the ill coworkers replacement travels in to work. What action by the charge nurse is indicated?
v v v v v v v v v v v v v v v v
1. Make no changes until the replacement nurse arrives.
v v v v v v v
2. Assign the less acute patients to be cared for by the unlicensed assistive personnel.
v v v v v v v v v v v v v
3. Assign the unlicensed assistive personnel to watch the monitors and call for help if a patient gets into
v v v v v v v v v v v v v v v v v
vtrouble.
4. Contact the house supervisor and ask for a float nurse to be sent to the unit. Correct Answer: 4
v v v v v v v v v v v v v v v v v v
Rationale 1: The unit is understaffed. Replacement help must be provided. It is inappropriate to wait for
v v v v v v v v v v v v v v v v
vthe replacement nurse.
v v
Rationale 2: The unlicensed assistive personnel are only able to provide care under the direct supervision
v v v v v v v v v v v v v v v
vof the nurse.
v v
Rationale 3: Watching monitors is not within the job description of the unlicensed assistive personnel and
v v v v v v v v v v v v v v v
vis not appropriate. The manager would be putting both patient safety and the unlicensed assistive
v v v v v v v v v v v v v v
vpersonnel at risk. v v
Rationale 4: The manager should obtain help until the replacement nurse arrives. Contacting the house
v v v v v v v v v v v v v v
vsupervisor and asking for a temporary float nurse is the best intervention.
v v v v v v v v v v v
Global Rationale: v
Cognitive Level: Analyzing v v
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
v v v v v v v v v v v
v Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-2 v v v v v v v
Question 5 Type: MCSA v v v
A recent nursing school graduate reports having an interview with a magnet hospital. When preparing
v v v v v v v v v v v v v v
for the interview, the graduate nurse researches the concept of magnet status. Which perceptions by the
v v v v v v v v v v v v v v v v
nurse indicate an adequate understanding?
v v v v v
1. Magnet status is an accreditation from the National League for Nurses.
v v v v v v v v v v
2. Magnet status facilities pay substantial recruitment bonuses.
v v v v v v
3. Magnet status facilities promote the interests of professional nursing.
v v v v v v v v
4. Magnet status hospitals must establish nurse-to-patient ratios. Correct Answer: 3
v v v v v v v v v
4|P a g e
v v v v v
v v v v v
Edition
v
byKathleenWagner, MelanieHardin-
Pierce,DarleneWelsh&KarenJohnson
All Chapters 1-39 With Rationales| A+ PASS
v v v v v v
1|P a g
v v v v
e
v
, Chapter 1. High-Acuity Nursing v v v
Question 1 v
v Type:
v MCSA
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate of
v v v v v v v v v v v v v v v
29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this
v v v v v v v v v v v v v v v
patient to be which priority for transfer to the intensive care unit (ICU)?
v v v v v v v v v v v v v
1. Priority 1 v
2. Priority 2 v
3. Priority 3 v
4. Priority 4 v
Correct Answer: 1 v v
Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or
v v v v v v v v v v v v v v v
other intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive
v v v v v v v v v v v v v v v
treatment and monitoring not provided outside of the ICU.
v v v v v v v v v
Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additional
v v v v v v v v v v v v v v
interventions. They are typically not evolving an acute event as is the case with this patient.
v v v v v v v v v v v v v v v v
Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their
v v v v v v v v v v v v v v v
illnesses. Limits are placed on therapeutic interventions and they can be cared for in areas other
v v v v v v v v v v v v v v v v
than the ICU if necessary.
v v v v v
Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment
v v v v v v v v v v v v v v v
are necessary.
v v
Global Rationale: v
Cognitive Level: Analyzing v v
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
v v v v v v v v v v v
v Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-1 v v v v v v v
Question 2 Type: MCSA v v v
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care
v v v v v v v v v v v v v v v v v
unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father
v v v v v v v v v v v v v v v v v v
may not receive close observation on a busy hospital unit. Which action is indicated by the nurse?
v v v v v v v v v v v v v v v v v
1. Notify the intensive care unit of an impending transfer.
v v v v v v v v
2. Tell the daughter that her father does not meet criteria for placement in the more expensive ICU.
v v v v v v v v v v v v v v v v
3. Discuss the care that can be provided on the unit with the family member.
v v v v v v v v v v v v v
2|P a g v v v v
ve
,4. Contact the physician. v v
Correct Answer: 3
v v v
Rationale 1: The nurse cannot make this transfer decision independently.
v v v v v v v v v
Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not therapeutic.
v v v v v v v v v v v v v v v v
vBringing up the issue of cost may cause the daughter to offer to pay the difference between the costs of
v v v v v v v v v v v v v v v v v v v
vthe two units. This would create a serious ethical dilemma.
v v v v v v v v v
Rationale 3: The best initial response is to help the daughter understand the level of care and observation
v v v v v v v v v v v v v v v v v
vthat will be provided on the MSCU so as to help her understand that her fathers care will be a priority.
v v v v v v v v v v v v v v v v v v v v
Rationale 4: The nurse should try to intervene in this situation before involving the physician. Global
v v v v v v v v v v v v v v v
vRationale:
Cognitive Level: Analyzing v v
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
v v v v v v v v v v v
v Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-1 v v v v v v v
Question 3 Type: MCSA v v v
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and
v v v v v v v v v v v v v v v v v
weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care
v v v v v v v v v v v v v v v v
environment?
v
1. Feels comfortable in ever changing situations
v v v v v
2. Closely evaluates the pros and cons of each decision for a long period of time before making a decision
v v v v v v v v v v v v v v v v v v
3. Is quiet and introverted
v v v
4. Is excited about all new experiences Correct Answer: 1
v v v v v v v v
Rationale 1: The nurse in the intensive care unit must be open to ever-changing situations. The nurse must
v v v v v v v v v v v v v v v v v
vbe flexible. v
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when considering
v v v v v v v v v v v v v v v v v
vactions.
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high- acuity
v v v v v v v v v v v v v v v v v v
care unit due to the need for teamwork and interaction.
v v v v v v v v v v
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the
v v v v v v v v v v v v v v v
most important factor for this particular care unit.
v v v v v v v v
Global Rationale: v
Cognitive Level: Analyzing v v
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
v v v v v v v v v v v
3|P a g e
v v v v v
, Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1-2 v v v v v v v
Question 4 Type: MCSA v v v
The registered nurse is working as charge nurse on a busy high-acuity care unit. Unexpectedly, a
v v v v v v v v v v v v v v v
vcoworker becomes ill and needs to leave. There is a period of time in which the unit is short staffed
v v v v v v v v v v v v v v v v v v v
vwhile the ill coworkers replacement travels in to work. What action by the charge nurse is indicated?
v v v v v v v v v v v v v v v v
1. Make no changes until the replacement nurse arrives.
v v v v v v v
2. Assign the less acute patients to be cared for by the unlicensed assistive personnel.
v v v v v v v v v v v v v
3. Assign the unlicensed assistive personnel to watch the monitors and call for help if a patient gets into
v v v v v v v v v v v v v v v v v
vtrouble.
4. Contact the house supervisor and ask for a float nurse to be sent to the unit. Correct Answer: 4
v v v v v v v v v v v v v v v v v v
Rationale 1: The unit is understaffed. Replacement help must be provided. It is inappropriate to wait for
v v v v v v v v v v v v v v v v
vthe replacement nurse.
v v
Rationale 2: The unlicensed assistive personnel are only able to provide care under the direct supervision
v v v v v v v v v v v v v v v
vof the nurse.
v v
Rationale 3: Watching monitors is not within the job description of the unlicensed assistive personnel and
v v v v v v v v v v v v v v v
vis not appropriate. The manager would be putting both patient safety and the unlicensed assistive
v v v v v v v v v v v v v v
vpersonnel at risk. v v
Rationale 4: The manager should obtain help until the replacement nurse arrives. Contacting the house
v v v v v v v v v v v v v v
vsupervisor and asking for a temporary float nurse is the best intervention.
v v v v v v v v v v v
Global Rationale: v
Cognitive Level: Analyzing v v
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
v v v v v v v v v v v
v Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-2 v v v v v v v
Question 5 Type: MCSA v v v
A recent nursing school graduate reports having an interview with a magnet hospital. When preparing
v v v v v v v v v v v v v v
for the interview, the graduate nurse researches the concept of magnet status. Which perceptions by the
v v v v v v v v v v v v v v v v
nurse indicate an adequate understanding?
v v v v v
1. Magnet status is an accreditation from the National League for Nurses.
v v v v v v v v v v
2. Magnet status facilities pay substantial recruitment bonuses.
v v v v v v
3. Magnet status facilities promote the interests of professional nursing.
v v v v v v v v
4. Magnet status hospitals must establish nurse-to-patient ratios. Correct Answer: 3
v v v v v v v v v
4|P a g e
v v v v v
