Test Bank Complete_
High-Acuity Nursing 7th Edition,
By Kathleen Wagner, Melanie Hardin-Pierce, Darlene Welsh, Karen Johnson
All Chapters 1-39| 10 Units| Latest Version With Detailed Answers| Grade A+
From: [Bestmaxsolutions.Stuvia
,PART 1: INTRODUCTION TO HIGH-ACUITY NURSING ------------------------------------------------------- 4
Chapter 1. High-Acuity Nursing -------------------------------------------------------------------------------------------4
Chapter 2. Holistic Care Of The Patient And Family --------------------------------------------------------------- 21
Chapter 3. Palliative And End-Of-Life Care -------------------------------------------------------------------------- 38
Chapter 4. The Older Adult High-Acuity Patient ------------------------------------------------------------------- 48
PART 2: THERAPEUTIC SUPPORT OF THE HIGH-ACUITY PATIENT -------------------------------------- 64
Chapter 5. Acute Pain Management ---------------------------------------------------------------------------------- 64
Chapter 6. Nutrition Support -------------------------------------------------------------------------------------------- 80
Chapter 7. Mechanical Ventilation ------------------------------------------------------------------------------------ 96
Chapter 8. Basic Hemodynamic Monitoring----------------------------------------------------------------------- 112
Chapter 9. Basic Cardiac Rhythm Monitoring --------------------------------------------------------------------- 128
Chapter 10. Complex Wound Management ----------------------------------------------------------------------- 143
PART 3: PULMONARY ------------------------------------------------------------------------------------------- 158
Chapter 11. Determinants And Assessment Of Pulmonary Function --------------------------------------- 158
Chapter 12. Alterations In Pulmonary Function ------------------------------------------------------------------ 174
PART 4: CARDIOVASCULAR ------------------------------------------------------------------------------------ 190
Chapter 13. Determinants And Assessment Of Cardiac Function-------------------------------------------- 190
Chapter 14. Alterations In Cardiac Function ---------------------------------------------------------------------- 206
Chapter 15. Alterations In Myocardial Tissue Perfusion ------------------------------------------------------- 221
PART 5: NEUROLOGIC ------------------------------------------------------------------------------------------- 237
Chapter 16. Determinants And Assessment Of Cerebral Function ------------------------------------------ 237
Chapter 17. Mentation And Sensory Motor Complications Of Acute Illness ----------------------------- 253
Chapter 18. Acute Stroke Injury -------------------------------------------------------------------------------------- 268
Chapter 19. Traumatic Brain Injury ---------------------------------------------------------------------------------- 284
Chapter 20. Acute Spinal Cord Injury ------------------------------------------------------------------------------- 300
PART 6: GASTROINTESTINAL ---------------------------------------------------------------------------------- 316
Chapter 21. Determinants And Assessment Of Gastrointestinal Function -------------------------------- 316
Chapter 22. Alterations In Gastrointestinal Function ----------------------------------------------------------- 332
Chapter 23. Alterations In Liver Function -------------------------------------------------------------------------- 348
Chapter 24. Alterations In Pancreatic Function ------------------------------------------------------------------ 363
PART 7: FLUID AND ELECTROLYTES -------------------------------------------------------------------------- 379
, Chapter 25. Determinants And Assessment Of Fluid And Electrolyte Balance --------------------------- 379
Chapter 26. Alterations In Fluid And Electrolyte Balance ------------------------------------------------------ 394
Chapter 27. Alterations In Kidney Function ----------------------------------------------------------------------- 409
PART 8: HEMATOLOGIC----------------------------------------------------------------------------------------- 426
Chapter 28. Determinants And Assessment Of Hematologic Function ------------------------------------ 426
Chapter 29. Alterations In Red Blood Cell Function And Hemostasis --------------------------------------- 442
Chapter 30. Alterations In White Blood Cell Function And Oncologic Emergencies -------------------- 457
PART 9: NUTRITION AND METABOLISM ------------------------------------------------------------------- 473
Chapter 31. Determinants And Assessment Of Nutrition And Metabolic Function --------------------- 473
Chapter 32. Metabolic Response To Stress ------------------------------------------------------------------------ 488
Chapter 33. Diabetic Crises -------------------------------------------------------------------------------------------- 502
PART 10: MULTISYSTEM DYSFUNCTION -------------------------------------------------------------------- 517
Chapter 34. Determinants And Assessment Of Oxygenation ------------------------------------------------- 517
Chapter 35. Multiple Trauma ----------------------------------------------------------------------------------------- 533
Chapter 36. Acute Burn Injury ---------------------------------------------------------------------------------------- 549
Chapter 37. Shock States ----------------------------------------------------------------------------------------------- 565
Chapter 38. Multiple Organ Dysfunction Syndrome ------------------------------------------------------------ 580
Chapter 39. Solid Organ And Hematopoietic Stem Cell Transplantation ---------------------------------- 595
,PART 1: INTRODUCTION TO HIGH-ACUITY NURSING
Chapter 1. High-Acuity Nursing
Kathleen Wagner: High-Acuity Nursing 7th Edition, Test Bank
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)?
1. Priority 1
2. Priority 2
3. Priority 3
4. Priority 4
ANS: 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 Need Additional 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 Other Than The ICU If Necessary.
Rationale 4: Priority 4 Patients Have No Signs Or Symptoms That Indicate Intensive
Monitoring Or Treatment 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 Medical surgical 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. Which Action 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 Expensive ICU.
3. Discuss The Care That Can Be Provided On The Unit With The Family Member.
4. Contact The Physician.
ANS: 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.
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
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 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
3. Is Quiet And Introverted
4. Is Excited About All New Experiences
ANS: 1
Rationale 1: The Nurse In The Intensive Care Unit Must Be Open To Ever-Changing
Situations. The Nurse Must Be Flexible.
Rationale 2: The Rapid Changes In The Intensive Care Unit Do Not Allow For Extended
Time When Considering 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 Is Not 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, A Coworker 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 Is Indicated?
High-Acuity Nursing 7th Edition,
By Kathleen Wagner, Melanie Hardin-Pierce, Darlene Welsh, Karen Johnson
All Chapters 1-39| 10 Units| Latest Version With Detailed Answers| Grade A+
From: [Bestmaxsolutions.Stuvia
,PART 1: INTRODUCTION TO HIGH-ACUITY NURSING ------------------------------------------------------- 4
Chapter 1. High-Acuity Nursing -------------------------------------------------------------------------------------------4
Chapter 2. Holistic Care Of The Patient And Family --------------------------------------------------------------- 21
Chapter 3. Palliative And End-Of-Life Care -------------------------------------------------------------------------- 38
Chapter 4. The Older Adult High-Acuity Patient ------------------------------------------------------------------- 48
PART 2: THERAPEUTIC SUPPORT OF THE HIGH-ACUITY PATIENT -------------------------------------- 64
Chapter 5. Acute Pain Management ---------------------------------------------------------------------------------- 64
Chapter 6. Nutrition Support -------------------------------------------------------------------------------------------- 80
Chapter 7. Mechanical Ventilation ------------------------------------------------------------------------------------ 96
Chapter 8. Basic Hemodynamic Monitoring----------------------------------------------------------------------- 112
Chapter 9. Basic Cardiac Rhythm Monitoring --------------------------------------------------------------------- 128
Chapter 10. Complex Wound Management ----------------------------------------------------------------------- 143
PART 3: PULMONARY ------------------------------------------------------------------------------------------- 158
Chapter 11. Determinants And Assessment Of Pulmonary Function --------------------------------------- 158
Chapter 12. Alterations In Pulmonary Function ------------------------------------------------------------------ 174
PART 4: CARDIOVASCULAR ------------------------------------------------------------------------------------ 190
Chapter 13. Determinants And Assessment Of Cardiac Function-------------------------------------------- 190
Chapter 14. Alterations In Cardiac Function ---------------------------------------------------------------------- 206
Chapter 15. Alterations In Myocardial Tissue Perfusion ------------------------------------------------------- 221
PART 5: NEUROLOGIC ------------------------------------------------------------------------------------------- 237
Chapter 16. Determinants And Assessment Of Cerebral Function ------------------------------------------ 237
Chapter 17. Mentation And Sensory Motor Complications Of Acute Illness ----------------------------- 253
Chapter 18. Acute Stroke Injury -------------------------------------------------------------------------------------- 268
Chapter 19. Traumatic Brain Injury ---------------------------------------------------------------------------------- 284
Chapter 20. Acute Spinal Cord Injury ------------------------------------------------------------------------------- 300
PART 6: GASTROINTESTINAL ---------------------------------------------------------------------------------- 316
Chapter 21. Determinants And Assessment Of Gastrointestinal Function -------------------------------- 316
Chapter 22. Alterations In Gastrointestinal Function ----------------------------------------------------------- 332
Chapter 23. Alterations In Liver Function -------------------------------------------------------------------------- 348
Chapter 24. Alterations In Pancreatic Function ------------------------------------------------------------------ 363
PART 7: FLUID AND ELECTROLYTES -------------------------------------------------------------------------- 379
, Chapter 25. Determinants And Assessment Of Fluid And Electrolyte Balance --------------------------- 379
Chapter 26. Alterations In Fluid And Electrolyte Balance ------------------------------------------------------ 394
Chapter 27. Alterations In Kidney Function ----------------------------------------------------------------------- 409
PART 8: HEMATOLOGIC----------------------------------------------------------------------------------------- 426
Chapter 28. Determinants And Assessment Of Hematologic Function ------------------------------------ 426
Chapter 29. Alterations In Red Blood Cell Function And Hemostasis --------------------------------------- 442
Chapter 30. Alterations In White Blood Cell Function And Oncologic Emergencies -------------------- 457
PART 9: NUTRITION AND METABOLISM ------------------------------------------------------------------- 473
Chapter 31. Determinants And Assessment Of Nutrition And Metabolic Function --------------------- 473
Chapter 32. Metabolic Response To Stress ------------------------------------------------------------------------ 488
Chapter 33. Diabetic Crises -------------------------------------------------------------------------------------------- 502
PART 10: MULTISYSTEM DYSFUNCTION -------------------------------------------------------------------- 517
Chapter 34. Determinants And Assessment Of Oxygenation ------------------------------------------------- 517
Chapter 35. Multiple Trauma ----------------------------------------------------------------------------------------- 533
Chapter 36. Acute Burn Injury ---------------------------------------------------------------------------------------- 549
Chapter 37. Shock States ----------------------------------------------------------------------------------------------- 565
Chapter 38. Multiple Organ Dysfunction Syndrome ------------------------------------------------------------ 580
Chapter 39. Solid Organ And Hematopoietic Stem Cell Transplantation ---------------------------------- 595
,PART 1: INTRODUCTION TO HIGH-ACUITY NURSING
Chapter 1. High-Acuity Nursing
Kathleen Wagner: High-Acuity Nursing 7th Edition, Test Bank
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)?
1. Priority 1
2. Priority 2
3. Priority 3
4. Priority 4
ANS: 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 Need Additional 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 Other Than The ICU If Necessary.
Rationale 4: Priority 4 Patients Have No Signs Or Symptoms That Indicate Intensive
Monitoring Or Treatment 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 Medical surgical 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. Which Action 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 Expensive ICU.
3. Discuss The Care That Can Be Provided On The Unit With The Family Member.
4. Contact The Physician.
ANS: 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.
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
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 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
3. Is Quiet And Introverted
4. Is Excited About All New Experiences
ANS: 1
Rationale 1: The Nurse In The Intensive Care Unit Must Be Open To Ever-Changing
Situations. The Nurse Must Be Flexible.
Rationale 2: The Rapid Changes In The Intensive Care Unit Do Not Allow For Extended
Time When Considering 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 Is Not 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, A Coworker 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 Is Indicated?
