TEST BANK
High-Acuity Nursing, 7th edition
by Kathleen Wagner, Melanie Hardin-Pierce
SC
O
R
EG
U
ID
ES
, TABLE OF CONTENT
PART 1: INTRODUCTION TO HIGH-ACUITY NURSING
1. High-Acuity Nursing
2. Holistic Care of the Patient and Family
3. Palliative and End-of-life Care
4. The Older Adult High-Acuity Patient
PART 2: THERAPEUTIC SUPPORT OF THE HIGH-ACUITY PATIENT
5. Acute Pain Management
6. Nutrition Support
7. Mechanical Ventilation
8. Basic Hemodynamic Monitoring
SC
9. Basic Cardiac Rhythm Monitoring
10. Complex Wound Management
PART 3: PULMONARY
11. Determinants and Assessment of Pulmonary Function
12. Alterations in Pulmonary Function
PART 4: CARDIOVASCULAR
O
13. Determinants and Assessment of Cardiac Function
14. Alterations in Cardiac Function
15. Alterations in Myocardial Tissue Perfusion
R
PART 5: NEUROLOGIC
16. Determinants and Assessment of Cerebral Function
17. Mentation and Sensory Motor Complications of Acute Illness
EG
18. Acute Stroke Injury
19. Traumatic Brain Injury
20. Acute Spinal Cord Injury
PART 6: GASTROINTESTINAL
21. Determinants and Assessment of Gastrointestinal Function
22. Alterations in Gastrointestinal Function
23. Alterations in Liver Function
U
24. Alterations in Pancreatic Function
PART 7: FLUID AND ELECTROLYTES
25. Determinants and Assessment of Fluid and Electrolyte Balance
ID
26. Alterations in Fluid and Electrolyte Balance
27. Alterations in Kidney Function
PART 8: HEMATOLOGIC
28. Determinants and Assessment of Hematologic Function
ES
29. Alterations in Red Blood Cell Function and Hemostasis
30. Alterations in White Blood Cell Function and Oncologic Emergencies
PART 9: NUTRITION AND METABOLISM
31. Determinants and Assessment of Nutrition and Metabolic Function
32. Metabolic Response to Stress
33. Diabetic Crises
PART 10: MULTISYSTEM DYSFUNCTION
34. Determinants and Assessment of Oxygenation
35. Multiple Trauma
36. Acute Burn Injury
37. Shock States
38. Multiple Organ Dysfunction Syndrome
39. Solid Organ and Hematopoietic Stem Cell Transplantation
, Franklyn A Plus Pass
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)?
SC
1. Priority 1
2. Priority 2
3. Priority 3
4. Priority 4
O
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
R
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.
EG
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.
U
Fr
Global Rationale:
Cognitive Level: Analyzing
an
ID
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
kl
Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-1
yn
ES
Question 2 Type: MCSA
e
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care
A
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?
pl
1. Notify the intensive care unit of an impending transfer.
us
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.
Pa
2|Page
ss
, Franklyn A Plus Pass
4. Contact the 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.
SC
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
O
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-1
R
Question 3 Type: MCSA
EG
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
U
3. Is quiet and introverted
Fr
4. Is excited about all new experiences Correct Answer: 1
an
ID
Rationale 1: The nurse in the intensive care unit must be open to ever-changing situations. The nurse must
be flexible.
kl
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when considering
yn
actions.
ES
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high- acuity care
e
unit due to the need for teamwork and interaction.
A
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the
most important factor for this particular care unit.
pl
Global Rationale:
us
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
Pa
3|Page
ss
High-Acuity Nursing, 7th edition
by Kathleen Wagner, Melanie Hardin-Pierce
SC
O
R
EG
U
ID
ES
, TABLE OF CONTENT
PART 1: INTRODUCTION TO HIGH-ACUITY NURSING
1. High-Acuity Nursing
2. Holistic Care of the Patient and Family
3. Palliative and End-of-life Care
4. The Older Adult High-Acuity Patient
PART 2: THERAPEUTIC SUPPORT OF THE HIGH-ACUITY PATIENT
5. Acute Pain Management
6. Nutrition Support
7. Mechanical Ventilation
8. Basic Hemodynamic Monitoring
SC
9. Basic Cardiac Rhythm Monitoring
10. Complex Wound Management
PART 3: PULMONARY
11. Determinants and Assessment of Pulmonary Function
12. Alterations in Pulmonary Function
PART 4: CARDIOVASCULAR
O
13. Determinants and Assessment of Cardiac Function
14. Alterations in Cardiac Function
15. Alterations in Myocardial Tissue Perfusion
R
PART 5: NEUROLOGIC
16. Determinants and Assessment of Cerebral Function
17. Mentation and Sensory Motor Complications of Acute Illness
EG
18. Acute Stroke Injury
19. Traumatic Brain Injury
20. Acute Spinal Cord Injury
PART 6: GASTROINTESTINAL
21. Determinants and Assessment of Gastrointestinal Function
22. Alterations in Gastrointestinal Function
23. Alterations in Liver Function
U
24. Alterations in Pancreatic Function
PART 7: FLUID AND ELECTROLYTES
25. Determinants and Assessment of Fluid and Electrolyte Balance
ID
26. Alterations in Fluid and Electrolyte Balance
27. Alterations in Kidney Function
PART 8: HEMATOLOGIC
28. Determinants and Assessment of Hematologic Function
ES
29. Alterations in Red Blood Cell Function and Hemostasis
30. Alterations in White Blood Cell Function and Oncologic Emergencies
PART 9: NUTRITION AND METABOLISM
31. Determinants and Assessment of Nutrition and Metabolic Function
32. Metabolic Response to Stress
33. Diabetic Crises
PART 10: MULTISYSTEM DYSFUNCTION
34. Determinants and Assessment of Oxygenation
35. Multiple Trauma
36. Acute Burn Injury
37. Shock States
38. Multiple Organ Dysfunction Syndrome
39. Solid Organ and Hematopoietic Stem Cell Transplantation
, Franklyn A Plus Pass
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)?
SC
1. Priority 1
2. Priority 2
3. Priority 3
4. Priority 4
O
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
R
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.
EG
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.
U
Fr
Global Rationale:
Cognitive Level: Analyzing
an
ID
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
kl
Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-1
yn
ES
Question 2 Type: MCSA
e
The daughter of a patient who is dying questions the placement of her father on the medicalsurgical care
A
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?
pl
1. Notify the intensive care unit of an impending transfer.
us
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.
Pa
2|Page
ss
, Franklyn A Plus Pass
4. Contact the 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.
SC
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
O
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-1
R
Question 3 Type: MCSA
EG
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
U
3. Is quiet and introverted
Fr
4. Is excited about all new experiences Correct Answer: 1
an
ID
Rationale 1: The nurse in the intensive care unit must be open to ever-changing situations. The nurse must
be flexible.
kl
Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when considering
yn
actions.
ES
Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high- acuity care
e
unit due to the need for teamwork and interaction.
A
Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not the
most important factor for this particular care unit.
pl
Global Rationale:
us
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
Pa
3|Page
ss
