HIGH ACUITY EXAM 1 QUESTIONS WITH CORRECT
RATIONALES
In cterms cof cfeeding cand cthe cmetabolic cstress cresponse, cthe cmajority cof cour chigh cacuity cpatients cshould cbe cfed cwhen?
A) cOnce cthey ccan ctake centeral cfeedings csafely.
B) cWithin chours cof cadmission.
C) cWithin c24 cto c48 chours cof cadmission cand cespecially cif cglucose cis cpoorly ccontrolled.
D) cAt cleast c24 chours cbefore cdischarge. c- cCORRECT cANS✔✔C
Your cpatient cis ca c79 cyo cfemale cthree cdays cpost cop cfrom corthopedic csurgery. cShe cpresents cwith cconfusion. cHer ctemperature
cis c37.9 c(up cfor cher) cRR cis c20, cBP c136/78 cand cHR c109. cShe cis con cDalteparin cfor cVTE cprophylaxis cand chas cSCDs cin
cplace. cHer cpain chas cbeen cwell ccontrolled con coral cmedications cand cshe chas cstarted cphysical ctherapy. cTo cprotect cher cskin
cthe cnurses chave cleft cher cfoley ccatheter cin cplace. cThere cis cno cevidence cof cskin cbreakdown. cWhat cis cyour cnursing cconcern?
A) cRisk cfor cpain cd/t cimmobility cas cevidenced cby c(AEB) ccontinued cneed cfor cpain cmedications con cpost cop cday c3.
B) cRisk cfor csubclinical cinfection c(r/t cage, cprolonged cfoley cinsertion) cAEB cConfusion, cincreased cHR, cslow cclimb cin
ctemperature.
C) cRisk cfor cvenous cstasis cd/t cimmobility cAEB cHR, cslight ctemperature.
D) cRisk cfor cimpaired ctissue cperfusion cd/t cimmobility cAEB cIncreasing cHR cand cnarrowing cpulse cpressure. c- cCORRECT
cANS✔✔B
Your cpatient cis ccurrently coriented, chowever che cwas cconfused cduring cthe cnight cshift clast cnight. cOn ca ctest cof cattention che
cgets c7/10. cHe cis ccurrently cat cbaseline cfor cbeing calert cand coriented c(RASS cO). cIs cthis ca ccomplete cenough cassessment cof
cdelirium?
A) cYes, cand che cis cCAM-
B) cYes, cand che cis cCAM+
C) cUTA c(unable cto cassess)
D) cThis cassessment cis cincomplete c(given cthe cfirst cthree cfindings), cyou cneed cto cassess cfor cdisorganized cthinking. c-
cCORRECT cANS✔✔D
Why care colder cadults cmore clikely cto cpresent cwith ca ccommon cproblem cin can cuncommon cway? c(Select call cthat capply.)
A) cThey care cat cgreater crisk cfor cinfection.
B) cThey ctake cmore cmedications.
C) cThey care cless clikely cto ccare cfor cthemselves cwell.
D) cThey care cless clikely cto cfollow ccare cinstructions ccorrectly.
E) cThey chave cmore ccomorbidities. c- cCORRECT cANS✔✔A, cB, cE
,When cshould cyou cinclude ca c2 cnurse csign coff con cmedications? cChoose call cthat capply.
A) cWhen cstarting cor cchanging cthe crate cof centeral cfeedings.
B) cWhen cadministering cany cmedication cvia cthe cintravenous croute.
C) cWhen cstarting cor cchanging cthe crate cof ca cHeparin cinfusion.
D) cWhen cstarting cor cchanging cthe crate cof can cInsulin cInfusion.
E) cWhen cadministrating ca cmedication cthat chas cnot cbeen cordered cby ca cphysician, cNP cor cPA.
F) cEvery cmedication crequires ca ctwo cnurse csign coff cto cinitiate.
G) cWhen cstarting, cchanging cthe crate cor cat cchange cof cshift cor ctransfer con ca cpatient cwith ca cPCA cor cepidural. c- cCORRECT
cANS✔✔C, cD, cG
Which cof cthe cfollowing cstatements cregarding cthe csimilarities cand cdifferences cbetween cDKA cand cHHS cis ccorrect?
A) cMental cstatus cchanges care cmore cprofound cin cHHS cthan cin cDKA.
B) cBoth care cassociated cwith ca chigh canion cgap cacidosis.
C) cDehydration cis cless csevere cin cHHS.
D) cThe conset cof cHHS cis cfaster cthan cthe conset cof cDKA. c- cCORRECT cANS✔✔A
Which cof cthe cfollowing clab cvalues cwould cbe cMOST ccritical cto creport cimmediately cto cthe cresident?
A) cA cserum cglucose cthat cdrops cby c150mg/dL cin cone chour cin ca cpatient con c0.1u/kg cinsulin cinfusion cfor cDKA.
B) cA cpaO2 cof c70 cin ca cpatient cwith cknown cCOPD cwho cis con croom cair.
C) cA cserum cK+ cof c5.8 cmEq/dL cin ca cpatient con c5units/hour cinsulin cinfusion.
D) cA cserum cNa+ cthat cincreases cby c10mEq cover ca c24 chour cperiod con chypertonic csaline. c- cCORRECT cANS✔✔A
Which cof cthe cfollowing cwill cTEMPORARILY cmove cK+ cfrom cthe cintravascular cspace c(the cplasma) cinto cthe ccells?
A) cInsulin cand cglucose.
B) cKayexilate.
C) cDialysis.
D) cAll cof cthe cabove. c- cCORRECT cANS✔✔A
In cwhich cof cthe cfollowing csituations cwould can cisotonic cfluid cbe ccontraindicated?
A) cIn ca cpatient cwith cdiabetes cmellitus.
B) cIn ca cpatient cwith chypotension.
C) cIn ca cpatient cwith chypertension cd/t cintravascular cfluid coverload.
D) cIn ca cpatient cwith ca clow cserum ccalcium clevel. c- cCORRECT cANS✔✔C
Which cof cthe cfollowing care cthe ctwo cmost cprevalent cendocrine cconcerns cin cthe colder cadult?
A) cHyperthyroidism cand cHyperparathyroidism.
B) cThere care cno cnormal cage crelated cchanges cthat caffect cendocrine chormones.
C) cDiabetes cMellitus cand cHypothyroidism.
D) cAdrenal cinsufficiency cand chypoparathyroidism. c- cCORRECT cANS✔✔C
Which cstatement cabout cintermediate ccare cunits cis ccorrect?
A) cThey care coutdated cand cshould cnot cbe cused.
B) cThey care clabor cintensive cand care cnot ccost ceffective.
C) cThey cprovide can cefficient cdistribution cof cresources.
, D) cThey care creserved cfor cclients cwith clife-threatening cillnesses. c- cCORRECT cANS✔✔C
Which cpriority clevel cindicates cthat cthe cclient cis cacutely cill cand cunstable cand crequires cintensive ctreatment cand cmonitoring cthat
ccannot cbe cprovided coutside cthe cICU?
A) cPriority c1
B) cPriority c2
C) cPriority c3
D) cPriority c4 c- cCORRECT cANS✔✔A
Evidence csuggest cthat cwhich cof cthe cfollowing cfactors creduces cmortality cand clife-threatening ccomplications cin cthe chospitalized
cclient?
A) cA cnurse-client cratio cof c1:2.
B) cConstant csurveillance cof cclients cby cnurses.
C) cHigh-technology cICUs.
D) cIMCs c- cCORRECT cANS✔✔B
A chospital cwith can cICU cthat chas cthe ccapability cof cproviding ccomprehensive ccare cto cmost ccritically cill cclients cbut cnot cto
ctrauma cclients cmeets cthe ccriteria cfor cwhich clevel cICU?
A) cI
B) cII
C) cIII
D) cIV c- cCORRECT cANS✔✔B
Which cstatement cis caccurate cconcerning cunlicensed cas cassistive cpersonnel c(UAP)?
A) cUAP cmay cnot cwork cin chigh-acuity cenvironments
B) cUAP cmay cwork cindependently cas clong cas cthey cnotify cthe cRN cat cthe cend cof ctheir cshifts.
C) cUAP cperform conly cthose ctasks cdelegated cto cthem cby ca cprofessional cnurse.
D) cUAP care cnot cgoverned cby cstate cboards cof cnursing. c- cCORRECT cANS✔✔C
What cdoes cthe cdesignation cof cMagnet cstatus cindicate?
A) cThe chospital cuses cUAP cto cdeliver cmost cnursing ccare.
B) cThe chospital cuses cpractice cmodels cthat cpromote cprofessional cnursing. c
C) cThe chospital chas clow cnurse-client cratios.
D) cThe chospital cis cnot ca cdesirable cplace cfor cprofessional cnurses cto cwork. c- cCORRECT cANS✔✔B
According cto csome, cICU cresources cshould cbe cused cfor cwhich cclients?
A) cThose cwith ccancer.
B) cThose cwith cadvanced cage.
C) cThose cwith cDNR corders.
D) cThose cwho chave cthe cgreatest cpossibility cof cbenefiting. c- cCORRECT cANS✔✔D
Which cstatement cis ccorrect cregarding cthe cimprovement cof cthe cdeath cand cdying cexperience?
A) cIt cis ca cgoal cof cmodern cmedicine.
B) cIt cis cthe csole cresponsibility cof cthe chigh-acuity cnurse.
C) cIt cis cnot ca cstandard cof ccare cin chigh-acuity cunits. c
D) cIt cis cthe csole cresponsibility cof cthe cpalliative ccare cteam. c- cCORRECT cANS✔✔A
RATIONALES
In cterms cof cfeeding cand cthe cmetabolic cstress cresponse, cthe cmajority cof cour chigh cacuity cpatients cshould cbe cfed cwhen?
A) cOnce cthey ccan ctake centeral cfeedings csafely.
B) cWithin chours cof cadmission.
C) cWithin c24 cto c48 chours cof cadmission cand cespecially cif cglucose cis cpoorly ccontrolled.
D) cAt cleast c24 chours cbefore cdischarge. c- cCORRECT cANS✔✔C
Your cpatient cis ca c79 cyo cfemale cthree cdays cpost cop cfrom corthopedic csurgery. cShe cpresents cwith cconfusion. cHer ctemperature
cis c37.9 c(up cfor cher) cRR cis c20, cBP c136/78 cand cHR c109. cShe cis con cDalteparin cfor cVTE cprophylaxis cand chas cSCDs cin
cplace. cHer cpain chas cbeen cwell ccontrolled con coral cmedications cand cshe chas cstarted cphysical ctherapy. cTo cprotect cher cskin
cthe cnurses chave cleft cher cfoley ccatheter cin cplace. cThere cis cno cevidence cof cskin cbreakdown. cWhat cis cyour cnursing cconcern?
A) cRisk cfor cpain cd/t cimmobility cas cevidenced cby c(AEB) ccontinued cneed cfor cpain cmedications con cpost cop cday c3.
B) cRisk cfor csubclinical cinfection c(r/t cage, cprolonged cfoley cinsertion) cAEB cConfusion, cincreased cHR, cslow cclimb cin
ctemperature.
C) cRisk cfor cvenous cstasis cd/t cimmobility cAEB cHR, cslight ctemperature.
D) cRisk cfor cimpaired ctissue cperfusion cd/t cimmobility cAEB cIncreasing cHR cand cnarrowing cpulse cpressure. c- cCORRECT
cANS✔✔B
Your cpatient cis ccurrently coriented, chowever che cwas cconfused cduring cthe cnight cshift clast cnight. cOn ca ctest cof cattention che
cgets c7/10. cHe cis ccurrently cat cbaseline cfor cbeing calert cand coriented c(RASS cO). cIs cthis ca ccomplete cenough cassessment cof
cdelirium?
A) cYes, cand che cis cCAM-
B) cYes, cand che cis cCAM+
C) cUTA c(unable cto cassess)
D) cThis cassessment cis cincomplete c(given cthe cfirst cthree cfindings), cyou cneed cto cassess cfor cdisorganized cthinking. c-
cCORRECT cANS✔✔D
Why care colder cadults cmore clikely cto cpresent cwith ca ccommon cproblem cin can cuncommon cway? c(Select call cthat capply.)
A) cThey care cat cgreater crisk cfor cinfection.
B) cThey ctake cmore cmedications.
C) cThey care cless clikely cto ccare cfor cthemselves cwell.
D) cThey care cless clikely cto cfollow ccare cinstructions ccorrectly.
E) cThey chave cmore ccomorbidities. c- cCORRECT cANS✔✔A, cB, cE
,When cshould cyou cinclude ca c2 cnurse csign coff con cmedications? cChoose call cthat capply.
A) cWhen cstarting cor cchanging cthe crate cof centeral cfeedings.
B) cWhen cadministering cany cmedication cvia cthe cintravenous croute.
C) cWhen cstarting cor cchanging cthe crate cof ca cHeparin cinfusion.
D) cWhen cstarting cor cchanging cthe crate cof can cInsulin cInfusion.
E) cWhen cadministrating ca cmedication cthat chas cnot cbeen cordered cby ca cphysician, cNP cor cPA.
F) cEvery cmedication crequires ca ctwo cnurse csign coff cto cinitiate.
G) cWhen cstarting, cchanging cthe crate cor cat cchange cof cshift cor ctransfer con ca cpatient cwith ca cPCA cor cepidural. c- cCORRECT
cANS✔✔C, cD, cG
Which cof cthe cfollowing cstatements cregarding cthe csimilarities cand cdifferences cbetween cDKA cand cHHS cis ccorrect?
A) cMental cstatus cchanges care cmore cprofound cin cHHS cthan cin cDKA.
B) cBoth care cassociated cwith ca chigh canion cgap cacidosis.
C) cDehydration cis cless csevere cin cHHS.
D) cThe conset cof cHHS cis cfaster cthan cthe conset cof cDKA. c- cCORRECT cANS✔✔A
Which cof cthe cfollowing clab cvalues cwould cbe cMOST ccritical cto creport cimmediately cto cthe cresident?
A) cA cserum cglucose cthat cdrops cby c150mg/dL cin cone chour cin ca cpatient con c0.1u/kg cinsulin cinfusion cfor cDKA.
B) cA cpaO2 cof c70 cin ca cpatient cwith cknown cCOPD cwho cis con croom cair.
C) cA cserum cK+ cof c5.8 cmEq/dL cin ca cpatient con c5units/hour cinsulin cinfusion.
D) cA cserum cNa+ cthat cincreases cby c10mEq cover ca c24 chour cperiod con chypertonic csaline. c- cCORRECT cANS✔✔A
Which cof cthe cfollowing cwill cTEMPORARILY cmove cK+ cfrom cthe cintravascular cspace c(the cplasma) cinto cthe ccells?
A) cInsulin cand cglucose.
B) cKayexilate.
C) cDialysis.
D) cAll cof cthe cabove. c- cCORRECT cANS✔✔A
In cwhich cof cthe cfollowing csituations cwould can cisotonic cfluid cbe ccontraindicated?
A) cIn ca cpatient cwith cdiabetes cmellitus.
B) cIn ca cpatient cwith chypotension.
C) cIn ca cpatient cwith chypertension cd/t cintravascular cfluid coverload.
D) cIn ca cpatient cwith ca clow cserum ccalcium clevel. c- cCORRECT cANS✔✔C
Which cof cthe cfollowing care cthe ctwo cmost cprevalent cendocrine cconcerns cin cthe colder cadult?
A) cHyperthyroidism cand cHyperparathyroidism.
B) cThere care cno cnormal cage crelated cchanges cthat caffect cendocrine chormones.
C) cDiabetes cMellitus cand cHypothyroidism.
D) cAdrenal cinsufficiency cand chypoparathyroidism. c- cCORRECT cANS✔✔C
Which cstatement cabout cintermediate ccare cunits cis ccorrect?
A) cThey care coutdated cand cshould cnot cbe cused.
B) cThey care clabor cintensive cand care cnot ccost ceffective.
C) cThey cprovide can cefficient cdistribution cof cresources.
, D) cThey care creserved cfor cclients cwith clife-threatening cillnesses. c- cCORRECT cANS✔✔C
Which cpriority clevel cindicates cthat cthe cclient cis cacutely cill cand cunstable cand crequires cintensive ctreatment cand cmonitoring cthat
ccannot cbe cprovided coutside cthe cICU?
A) cPriority c1
B) cPriority c2
C) cPriority c3
D) cPriority c4 c- cCORRECT cANS✔✔A
Evidence csuggest cthat cwhich cof cthe cfollowing cfactors creduces cmortality cand clife-threatening ccomplications cin cthe chospitalized
cclient?
A) cA cnurse-client cratio cof c1:2.
B) cConstant csurveillance cof cclients cby cnurses.
C) cHigh-technology cICUs.
D) cIMCs c- cCORRECT cANS✔✔B
A chospital cwith can cICU cthat chas cthe ccapability cof cproviding ccomprehensive ccare cto cmost ccritically cill cclients cbut cnot cto
ctrauma cclients cmeets cthe ccriteria cfor cwhich clevel cICU?
A) cI
B) cII
C) cIII
D) cIV c- cCORRECT cANS✔✔B
Which cstatement cis caccurate cconcerning cunlicensed cas cassistive cpersonnel c(UAP)?
A) cUAP cmay cnot cwork cin chigh-acuity cenvironments
B) cUAP cmay cwork cindependently cas clong cas cthey cnotify cthe cRN cat cthe cend cof ctheir cshifts.
C) cUAP cperform conly cthose ctasks cdelegated cto cthem cby ca cprofessional cnurse.
D) cUAP care cnot cgoverned cby cstate cboards cof cnursing. c- cCORRECT cANS✔✔C
What cdoes cthe cdesignation cof cMagnet cstatus cindicate?
A) cThe chospital cuses cUAP cto cdeliver cmost cnursing ccare.
B) cThe chospital cuses cpractice cmodels cthat cpromote cprofessional cnursing. c
C) cThe chospital chas clow cnurse-client cratios.
D) cThe chospital cis cnot ca cdesirable cplace cfor cprofessional cnurses cto cwork. c- cCORRECT cANS✔✔B
According cto csome, cICU cresources cshould cbe cused cfor cwhich cclients?
A) cThose cwith ccancer.
B) cThose cwith cadvanced cage.
C) cThose cwith cDNR corders.
D) cThose cwho chave cthe cgreatest cpossibility cof cbenefiting. c- cCORRECT cANS✔✔D
Which cstatement cis ccorrect cregarding cthe cimprovement cof cthe cdeath cand cdying cexperience?
A) cIt cis ca cgoal cof cmodern cmedicine.
B) cIt cis cthe csole cresponsibility cof cthe chigh-acuity cnurse.
C) cIt cis cnot ca cstandard cof ccare cin chigh-acuity cunits. c
D) cIt cis cthe csole cresponsibility cof cthe cpalliative ccare cteam. c- cCORRECT cANS✔✔A
