Test bank for High Acuity Nursing 7th Edition Wagne
v v v v v v v vv
r Pierce Welsh -latest-2023-2024
v v v
Chapterv1.vHigh-
AcuityvNursingvQuestionv1
Type:vMCSA
Thevpatientvwhovhadvsurgeryvyesterdayvreportsvhisvchestvfeelsvtight.vAssessmentvrevealsvrespirat
oryvratevofv29,vinspiratoryvwheezes,vstridor,vandvanvoxygenationvsaturationvofv80%.vThevnursevw
ouldvconsidervthisvpatientvtovbevwhichvpriorityvforvtransfervtovthevintensivevcarevunitv(ICU)?
1. Priorityv1
2. Priorityv2
3. Priorityv3
4. Priorityv4
CorrectvAnswer:v1
Rationalev1:vThisvpatientvisvexhibitingvsignsvofvanvacutevrespiratoryveventvforvwhichvintubationv
orvothervintensivevtreatmentvmayvbevnecessary.vPriorityv1vpatientsvarevacutelyvillvandvneedvinten
sivevtreatmentvandvmonitoringvnotvprovidedvoutsidevofvthevICU.
Rationalev2:vPriorityv2vrefersvtovpatientsvneedingvintensivevmonitoringvandvmayvpotentiallyvneedv
additionalvinterventions.vTheyvarevtypicallyvnotvevolvingvanvacuteveventvasvisvthevcasevwithvthisv
patient.
Rationalev3:vPriorityv3vpatientsvarevcriticallyvillvbutvhavevlittlevchancevofvrecoveryvfromvtheirvilln
esses.vLimitsvarevplacedvonvtherapeuticvinterventionsvandvtheyvcanvbevcaredvforvinvareasvothervtha
nvthevICUvifvnecessary.
Rationalev4:vPriorityv4vpatientsvhavevnovsignsvorvsymptomsvthatvindicatevintensivevmonitoringvor
vtreatmentvarevnecessary.
GlobalvRationale:
CognitivevLevel:vAnalyzing
ClientvNeed:vSafevEffectivevCarevEnvironmentvCli
entvNeedvSub:vManagementvofvCare
Nursing/IntegratedvConcepts:vNursingvProcess:vPlanningvLearn
ingvOutcome:v1-1
Questionv2vTyp
e:vMCSA
Thevdaughtervofvavpatientvwhovisvdyingvquestionsvthevplacementvofvhervfathervonvthevmedicalsur
gicalvcarevunitv(MSCU).vShevrequestsvhevbevplacedvinvthevintensivevcarevunitv(ICU)vbecausevofvc
oncernvhervfathervmayvnotvreceivevclosevobservationvonvavbusyvhospitalvunit.vWhichvactionvisvind
icatedvbyvthevnurse?
1. Notifyvthevintensivevcarevunitvofvanvimpendingvtransfer.
2. Tellvthevdaughtervthatvhervfathervdoesvnotvmeetvcriteriavforvplacementvinvthevmorevexpensiv
evICU.
3. Discussvthevcarevthatvcanvbevprovidedvonvthevunitvwithvthevfamilyvmember.
4. Contactvthevphysician.
CorrectvAnswer:v3
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Rationalev1:vThevnursevcannotvmakevthisvtransfervdecisionvindependently.
Rationalev2:vTellingvthevdaughtervthatvhervfathervdoesvnotvmeetvcriteriavforvtransfervisvnotvtherap
eutic.vBringingvupvthevissuevofvcostvmayvcausevthevdaughtervtovoffervtovpayvthevdifferencevbetwee
nvthevcostsvofvthevtwovunits.vThisvwouldvcreatevavseriousvethicalvdilemma.
Rationalev3:vThevbestvinitialvresponsevisvtovhelpvthevdaughtervunderstandvthevlevelvofvcarevandvob
servationvthatvwillvbevprovidedvonvthevMSCUvsovasvtovhelpvhervunderstandvthatvhervfathersvcarev
willvbevavpriority.
Rationalev4:vThevnursevshouldvtryvtovintervenevinvthisvsituationvbeforevinvolvingvthevphysician.vG
lobalvRationale:
CognitivevLevel:vAnalyzing
ClientvNeed:vSafevEffectivevCarevEnvironmentvCli
entvNeedvSub:vManagementvofvCare
Nursing/IntegratedvConcepts:vNursingvProcess:vImplementation
vLearningvOutcome:v1-1
Questionv3vTyp
e:vMCSA
Avnursevwhovisvcontemplatingvtakingvavpositionvinvanvintensivevcarevunitvisvreviewingvhervstreng
thsvandvweaknesses.vWhichvcharacteristicsvofvthevnursevwillvbevofvthevgreatestvbenefitvinvthevinte
nsivevcarevenvironment?
1. Feelsvcomfortablevinvevervchangingvsituations
2. Closelyvevaluatesvthevprosvandvconsvofveachvdecisionvforvavlongvperiodvofvtimevbeforevmaking
vavdecision
3. Isvquietvandvintroverted
4. Isvexcitedvaboutvallvnewvexperience
svCorrectvAnswer:v1
Rationalev1:vThevnursevinvthevintensivevcarevunitvmustvbevopenvtovever-
changingvsituations.vThevnursevmustvbevflexible.
Rationalev2:vThevrapidvchangesvinvthevintensivevcarevunitvdovnotvallowvforvextendedvtimevwhenvc
onsideringvactions.
Rationalev3:vAvquietvandvintrovertedvnursevmayvnotvbevavgoodvmatchvforvthevhighvpacedvhigh-
vacuityvcarevunitvduevtovthevneedvforvteamworkvandvinteraction.
Rationalev4:vExcitementvaboutvallvexperiencesvisvavbeneficialvcharacteristicvinvhealthcarevbutvisv
notvthevmostvimportantvfactorvforvthisvparticularvcarevunit.
GlobalvRationale:
CognitivevLevel:vAnalyzing
ClientvNeed:vSafevEffectivevCarevEnvironmentvCli
entvNeedvSub:vManagementvofvCare
Nursing/IntegratedvConcepts:vNursingvProcess:vAssessmen
tvLearningvOutcome:v1-2
Questionv4vTyp
e:vMCSA
Thevregisteredvnursevisvworkingvasvchargevnursevonvavbusyvhigh-
acuityvcarevunit.vUnexpectedly,vavcoworkervbecomesvillvandvneedsvtovleave.vTherevisvavperiodvofv
timevinvwhichvthevunitvisvshort
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staffedvwhilevthevillvcoworkersvreplacementvtravelsvinvtovwork.vWhatvactionvbyvthevchargevnursevisvindicat
ed?
1. Makevnovchangesvuntilvthevreplacementvnursevarrives.
2. Assignvthevlessvacutevpatientsvtovbevcaredvforvbyvthevunlicensedvassistivevpersonnel.
3. Assignvthevunlicensedvassistivevpersonnelvtovwatchvthevmonitorsvandvcallvforvhelpvifvavpatie
ntvgetsvintovtrouble.
4. Contactvthevhousevsupervisorvandvaskvforvavfloatvnursevtovbevsentvtovthevuni
t.vCorrectvAnswer:v4
Rationalev1:vThevunitvisvunderstaffed.vReplacementvhelpvmustvbevprovided.vItvisvinappropriatevtov
waitvforvthevreplacementvnurse.
Rationalev2:vThevunlicensedvassistivevpersonnelvarevonlyvablevtovprovidevcarevundervthevdirectvsu
pervisionvofvthevnurse.
Rationalev3:vWatchingvmonitorsvisvnotvwithinvthevjobvdescriptionvofvthevunlicensedvassistiv
evpersonnelvandvisvnotvappropriate.vThevmanagervwouldvbevputtingvbothvpatientvsafetyvandv
thevunlicensedvassistivevpersonnelvatvrisk.
Rationalev4:vThevmanagervshouldvobtainvhelpvuntilvthevreplacementvnursevarrives.vContactingvthe
vhousevsupervisorvandvaskingvforvavtemporaryvfloatvnursevisvthevbestvintervention.
GlobalvRationale:
CognitivevLevel:vAnalyzing
ClientvNeed:vSafevEffectivevCarevEnvironmentvCli
entvNeedvSub:vManagementvofvCare
Nursing/IntegratedvConcepts:vNursingvProcess:vImplementation
vLearningvOutcome:v1-2
Questionv5vTyp
e:vMCSA
Avrecentvnursingvschoolvgraduatevreportsvhavingvanvinterviewvwithvavmagnetvhospital.vWhenvpre
paringvforvthevinterview,vthevgraduatevnursevresearchesvthevconceptvofvmagnetvstatus.vWhichvperc
eptionsvbyvthevnursevindicatevanvadequatevunderstanding?
1. MagnetvstatusvisvanvaccreditationvfromvthevNationalvLeaguevforvNurses.
2. Magnetvstatusvfacilitiesvpayvsubstantialvrecruitmentvbonuses.
3. Magnetvstatusvfacilitiesvpromotevthevinterestsvofvprofessionalvnursing.
4. Magnetvstatusvhospitalsvmustvestablishvnurse-to-
patientvratios.vCorrectvAnswer:v3
Rationalev1:vMagnetvstatusvisvavdesignationvdevelopedvbyvthevAmericanvNursesvCredentialingvCe
nter.
Rationalev2:vFacilitiesvwithvmagnetvdesignationvattractvnursesvbecausevofvtheirvworkvenvironmen
t.vOftenvtherevisvnovneedvtovpayvrecruitmentvbonuses.
Rationalev3:vMagnetvstatusvisvawardedvtovhospitalsvthatvarevablevtovprovevtheirvcommitmentvtovpr
ofessionalvnursingvpractices.
Rationalev4:vNurse-to-
patientvratiosvarevnotvpartvofvthevmagnetvhospitalvdesignation.vGlobalvRationale:
CognitivevLevel:vAnalyzing
ClientvNeed:vSafevEffectivevCarevEnvironment
, ClientvNeedvSub:vManagementvofvCare
Nursing/IntegratedvConcepts:vNursingvProcess:vEvaluationvLea
rningvOutcome:v1-2
Questionv6vTyp
e:vMCSA
Avteamvofvnursesvwouldvlikevtovresearchvoutcomesvofvintensivevcarevthatvexpandvbeyondvthosevth
atvarevnormallyvstudied.vThisvteamvwouldvrecognizevwhichvoutcomevasvmostvcommonlyvstudied?
1. Patientvcomfort
2. Patientvperceivedvqualityvofvlife
3. Functionalvstatus
4. Mortality
CorrectvAnswer:v4
Rationalev1:vPatientvcomfortvisvavveryvimportantvoutcome,vbutvisvnotvthevonevmostvcommonlyvstu
died.
Rationalev2:vQualityvofvlifevaftervintensivevcarevisvavveryvimportantvoutcome,vbutvisvnotvthevonev
mostvcommonlyvstudied.
Rationalev3:vFunctionalvstatusvaftervtreatmentvinvthevintensivevcarevunitvisvavveryvimportantvoutco
me,vbutvisvnotvthevonevmostvcommonlyvstudied.
Rationalev4:vMortalityvisvthevmostvcommonlyvstudiedvoutcomevofvintensivevcarevtreatment.vGlo
balvRationale:
CognitivevLevel:vApplying
ClientvNeed:vSafevEffectivevCarevEnvironmentvCli
entvNeedvSub:vManagementvofvCare
Nursing/IntegratedvConcepts:vNursingvProcess:vAssessmen
tvLearningvOutcome:v1-2
Questionv7vTyp
e:vMCSA
Avnewlyvemployedvnursevisvworkingvwithvanvexperiencedvregisteredvnurse.vDuringvthevshift,vthev
experiencedvnursevroutinelyvusesvhervpersonalvdigitalvassistant.vHowvwouldvthevnursevexplainvthe
vusevofvthisvdevicevtovthevnovicevnurse?
1. IvusevmyvPDAvasvavreferencevtoolvseveralvtimesveveryvday.
2. IvcanvaccessvmyvpatientsvoldvmedicalvrecordsvonvthisvPDA.
3. IvusevmyvPDAvtovletvthevpharmacyvknowvwhenvIvneedvmedications.
4. IvusevmyvPDAvtovwritevnursingvnotes
.vCorrectvAnswer:v1
Rationalev1:vThevpersonalvdigitalvassistantv(PDA)visvusedvtovprovidevquickvbedsidevinformationvt
ovthevnurse.
Rationalev2:vThevpatientsvpersonalvmedicalvrecordsvwouldvnotvbevaccessiblevthroughvthevPDA.vR
ationalev3:vThevPDAvwouldvnotvbevusefulvforvthisvapplication.
Rationalev4:vThevnursevshouldvnotvrecordvnursingvnotesvonvthevPDA.vGl
obalvRationale:
CognitivevLevel:vApplying
ClientvNeed:vSafevEffectivevCarevEnvironment