Wagner, High Acuity Nursing, 6e Chapter 1 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 t he 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 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 hosp ital 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. 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. 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 father’s 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 Correct Answer: 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 impor tant 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 coworker's replacement travels in to work. What action by the charge nurse is indicated? 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 patient "gets 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 to wait for the replacement nurse. Rationale 2: The unlicensed assistive personnel are only able to provide care under the direct supervision 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 the unlicensed assistive personnel at risk.
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