lOMoAR cPSD| 12263423
Test Bank
High Acuity Nursing
By Wagner Pierce Welsh
7th Edition
, lOMoAR cPSD| 12263423
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%. TheNurse 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
NeedAdditional 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 OtherThan The ICU If Necessary.
Rationale 4: Priority 4 Patients Have No Signs Or Symptoms That Indicate Intensive
Monitoring OrTreatment 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. WhichAction 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
ExpensiveICU.
3. Discuss The Care That Can Be Provided On The Unit With The Family Member.
4. Contact The
Physician.
Correct Answer: 3
, lOMoAR cPSD| 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 DifferenceBetween 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 CareWill 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 TheIntensive 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 ADecision
3. Is Quiet And Introverted
4. Is Excited About All New
ExperiencesCorrect Answer: 1
Rationale 1: The Nurse In The Intensive Care Unit Must Be Open To Ever-Changing
Situations. TheNurse Must Be Flexible.
Rationale 2: The Rapid Changes In The Intensive Care Unit Do Not Allow For Extended
Time WhenConsidering 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 IsNot 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, ACoworker Becomes Ill And Needs To Leave. There Is A Period Of Time In
Which The Unit Is Short
, Staffed While The Ill Coworkers Replacement Travels In To Work. What Action By The Charge
Nurse IsIndicated?
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 PatientGets 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 ToWait For The Replacement Nurse.
Rationale 2: The Unlicensed Assistive Personnel Are Only Able To Provide Care Under The
DirectSupervision 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 TheUnlicensed Assistive Personnel At Risk.
Rationale 4: The Manager Should Obtain Help Until The Replacement Nurse Arrives.
Contacting TheHouse 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. WhichPerceptions 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
CredentialingCenter.
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 ToProfessional 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
Test Bank
High Acuity Nursing
By Wagner Pierce Welsh
7th Edition
, lOMoAR cPSD| 12263423
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%. TheNurse 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
NeedAdditional 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 OtherThan The ICU If Necessary.
Rationale 4: Priority 4 Patients Have No Signs Or Symptoms That Indicate Intensive
Monitoring OrTreatment 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. WhichAction 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
ExpensiveICU.
3. Discuss The Care That Can Be Provided On The Unit With The Family Member.
4. Contact The
Physician.
Correct Answer: 3
, lOMoAR cPSD| 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 DifferenceBetween 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 CareWill 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 TheIntensive 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 ADecision
3. Is Quiet And Introverted
4. Is Excited About All New
ExperiencesCorrect Answer: 1
Rationale 1: The Nurse In The Intensive Care Unit Must Be Open To Ever-Changing
Situations. TheNurse Must Be Flexible.
Rationale 2: The Rapid Changes In The Intensive Care Unit Do Not Allow For Extended
Time WhenConsidering 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 IsNot 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, ACoworker Becomes Ill And Needs To Leave. There Is A Period Of Time In
Which The Unit Is Short
, Staffed While The Ill Coworkers Replacement Travels In To Work. What Action By The Charge
Nurse IsIndicated?
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 PatientGets 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 ToWait For The Replacement Nurse.
Rationale 2: The Unlicensed Assistive Personnel Are Only Able To Provide Care Under The
DirectSupervision 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 TheUnlicensed Assistive Personnel At Risk.
Rationale 4: The Manager Should Obtain Help Until The Replacement Nurse Arrives.
Contacting TheHouse 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. WhichPerceptions 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
CredentialingCenter.
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 ToProfessional 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
