Test bank for High Acuity Nursing 7th Edition by Kathleen Dorman Wagner Melanie Hardin-Pierce Darlene Welsh 9780134459295 Chapter 1-39 All Chapters with Answers

Test Bank for High-Acuity Nursing 7th
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s3 Edition
by Kathleen Wagner, Melanie Hardin-
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s3 Pierce, Darlene Welsh & Karen Johnson
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All Chapters 1-39 With Rationales| A+ PASS
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, Chapter 1. High-Acuity Nursing s3 s3 s3




Question 1 s3




s3 Type:

MCSA
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The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory
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rate of 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would
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consider this patient to be which priority for transfer to the intensive care unit (ICU)?
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1. Priority 1 s3




2. Priority 2 s3




3. Priority 3 s3




4. Priority 4 s3




Correct Answer: 1 s3 s3




Rationale 1: This patient is exhibiting signs of an acute respiratory event for which intubation or
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other intensive treatment may be necessary. Priority 1 patients are acutely ill and need intensive
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treatment and monitoring not provided outside of the ICU.
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Rationale 2: Priority 2 refers to patients needing intensive monitoring and may potentially need additional
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interventions. They are typically not evolving an acute event as is the case with this patient.
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Rationale 3: Priority 3 patients are critically ill but have little chance of recovery from their
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illnesses. Limits are placed on therapeutic interventions and they can be cared for in areas other
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than the ICU if necessary.
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Rationale 4: Priority 4 patients have no signs or symptoms that indicate intensive monitoring or
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treatment are necessary.
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Global Rationale: s3




Cognitive Level: Analyzing s3 s3




Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
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s3 Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1-1 s3 s3 s3 s3 s3 s3 s3




Question 2 Type: MCSA s3 s3 s3




The daughter of a patient who is dying questions the placement of her father on the
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medicalsurgical care unit (MSCU). She requests he be placed in the intensive care unit (ICU)
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because of concern her father may not receive close observation on a busy hospital unit. Which
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action is indicated by the nurse?
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1. Notify the intensive care unit of an impending transfer.
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2. Tell the daughter that her father does not meet criteria for placement in the more expensive ICU.
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,3. Discuss the care that can be provided on the unit with the family member.
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, 4. Contact the s3


physician.
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Correct Answer: 3 s3 s3




Rationale 1: The nurse cannot make this transfer decision independently.
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Rationale 2: Telling the daughter that her father does not meet criteria for transfer is not
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therapeutic. Bringing up the issue of cost may cause the daughter to offer to pay the difference
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between the costs of the two units. This would create a serious ethical dilemma.
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Rationale 3: The best initial response is to help the daughter understand the level of care and
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observation that will be provided on the MSCU so as to help her understand that her fathers care
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will be a priority.
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Rationale 4: The nurse should try to intervene in this situation before involving the physician.
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Global Rationale:
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Cognitive Level: Analyzing s3 s3




Client Need: Safe Effective Care Environment Client Need Sub: Management of Care
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s3 Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1-1 s3 s3 s3 s3 s3 s3 s3




Question 3 Type: MCSA s3 s3 s3




A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths
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and weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive
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care environment?
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1. Feels comfortable in ever changing situations
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2. Closely evaluates the pros and cons of each decision for a long period of time before making a
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decision
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3. Is quiet and introverted
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4. Is excited about all new experiences Correct Answer: 1
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Rationale 1: The nurse in the intensive care unit must be open to ever-changing situations. The nurse
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must be flexible.
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Rationale 2: The rapid changes in the intensive care unit do not allow for extended time when
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considering actions.
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Rationale 3: A quiet and introverted nurse may not be a good match for the high paced high-
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acuity care unit due to the need for teamwork and interaction.
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Rationale 4: Excitement about all experiences is a beneficial characteristic in healthcare but is not
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the most important factor for this particular care unit.
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Global Rationale: s3




Cognitive Level: Analyzing s3 s3



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