lOMoARcPSD|12263423
Test Bank For High Acuity Nursing 7th Edition
Author:Wagner Pierce Welsh -Latest-2024-2025
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 Outcome: 1-1
Question 2 Type:
MCSA
The Daughter Of A Patient Who Is Dying Questions The Placement Of Her Father On The
Medicalsurgical 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. Contact The Physician.
Correct Answer: 3
, lOMoARcPSD|12263423
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
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
, lOMoARcPSD|12263423
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. Contact The House Supervisor And Ask For A Float Nurse To Be Sent
To The Unit. Correct Answer: 4
Rationale 1: The Unit Is Understaffed. Replacement Help Must Be Provided. It Is
Inappropriate To Wait For The Replacement Nurse.
Rationale 2: The Unlicensed Assistive Personnel Are Only Able To Provide Care Under
The Direct Supervision Of The Nurse.
Rationale 3: Watching Monitors Is Not Within The Job Description Of The Unlicensed
Assistive Personnel And Is Not Appropriate. The Manager Would Be Putting Both
Patient Safety And The Unlicensed Assistive Personnel At Risk.
Rationale 4: The Manager Should Obtain Help Until The Replacement Nurse Arrives.
Contacting The House Supervisor And Asking For A Temporary Float Nurse Is The Best
Intervention.
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: 1-2
Question 5
Type: MCSA
A Recent Nursing School Graduate Reports Having An Interview With A Magnet Hospital.
When Preparing For The Interview, The Graduate Nurse Researches The Concept Of
Magnet Status. Which Perceptions By The Nurse Indicate An Adequate Understanding?
1. Magnet Status Is An Accreditation From The National League For Nurses.
2. Magnet Status Facilities Pay Substantial Recruitment Bonuses.
3. Magnet Status Facilities Promote The Interests Of Professional Nursing.
4. Magnet Status Hospitals Must Establish Nurse-To-Patient
Ratios. Correct Answer: 3
Rationale 1: Magnet Status Is A Designation Developed By The American Nurses
Credentialing Center.
Rationale 2: Facilities With Magnet Designation Attract Nurses Because Of Their Work
Environment. Often There Is No Need To Pay Recruitment Bonuses.
Rationale 3: Magnet Status Is Awarded To Hospitals That Are Able To Prove Their
Commitment To Professional Nursing Practices.
Rationale 4: Nurse-To-Patient Ratios Are Not Part Of The Magnet Hospital
Designation. Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
, lOMoARcPSD|12263423
Test Bank For High Acuity Nursing 7th Edition
Author:Wagner Pierce Welsh -Latest-2024-2025
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 Outcome: 1-1
Question 2 Type:
MCSA
The Daughter Of A Patient Who Is Dying Questions The Placement Of Her Father On The
Medicalsurgical 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. Contact The Physician.
Correct Answer: 3
, lOMoARcPSD|12263423
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
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
, lOMoARcPSD|12263423
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. Contact The House Supervisor And Ask For A Float Nurse To Be Sent
To The Unit. Correct Answer: 4
Rationale 1: The Unit Is Understaffed. Replacement Help Must Be Provided. It Is
Inappropriate To Wait For The Replacement Nurse.
Rationale 2: The Unlicensed Assistive Personnel Are Only Able To Provide Care Under
The Direct Supervision Of The Nurse.
Rationale 3: Watching Monitors Is Not Within The Job Description Of The Unlicensed
Assistive Personnel And Is Not Appropriate. The Manager Would Be Putting Both
Patient Safety And The Unlicensed Assistive Personnel At Risk.
Rationale 4: The Manager Should Obtain Help Until The Replacement Nurse Arrives.
Contacting The House Supervisor And Asking For A Temporary Float Nurse Is The Best
Intervention.
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: 1-2
Question 5
Type: MCSA
A Recent Nursing School Graduate Reports Having An Interview With A Magnet Hospital.
When Preparing For The Interview, The Graduate Nurse Researches The Concept Of
Magnet Status. Which Perceptions By The Nurse Indicate An Adequate Understanding?
1. Magnet Status Is An Accreditation From The National League For Nurses.
2. Magnet Status Facilities Pay Substantial Recruitment Bonuses.
3. Magnet Status Facilities Promote The Interests Of Professional Nursing.
4. Magnet Status Hospitals Must Establish Nurse-To-Patient
Ratios. Correct Answer: 3
Rationale 1: Magnet Status Is A Designation Developed By The American Nurses
Credentialing Center.
Rationale 2: Facilities With Magnet Designation Attract Nurses Because Of Their Work
Environment. Often There Is No Need To Pay Recruitment Bonuses.
Rationale 3: Magnet Status Is Awarded To Hospitals That Are Able To Prove Their
Commitment To Professional Nursing Practices.
Rationale 4: Nurse-To-Patient Ratios Are Not Part Of The Magnet Hospital
Designation. Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
, lOMoARcPSD|12263423
