Test bank for High Acuity Nursing 7th Edition
Wagner Pierce Welsh -latest-2023-2024
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 ***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 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 EnvironmentClient
Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: PlanningLearning
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.
***ANS: 3
1
, 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 EnvironmentClient
Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: ImplementationLearning
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 experiences
***ANS: 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 EnvironmentClient
Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: AssessmentLearning
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
2
, lOMoAR cPSD| 12263423
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.***ANS: 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 the unlicensed 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 EnvironmentClient
Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: ImplementationLearning
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.***ANS: 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
3
, Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: EvaluationLearning
Outcome: 1-2
Question 6 Type:
MCSA
A team of nurses would like to research outcomes of intensive care that expand beyond those thatare normally
studied. This team would recognize which outcome as most commonly studied?
1. Patient comfort
2. Patient perceived quality of life
3. Functional status
4. Mortality ***ANS: 4
Rationale 1: Patient comfort is a very important outcome, but is not the one most commonlystudied.
Rationale 2: Quality of life after intensive care is a very important outcome, but is not the onemost commonly
studied.
Rationale 3: Functional status after treatment in the intensive care unit is a very importantoutcome, but is not
the one most commonly studied.
Rationale 4: Mortality is the most commonly studied outcome of intensive care treatment.Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care EnvironmentClient
Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: AssessmentLearning
Outcome: 1-2
Question 7 Type:
MCSA
A newly employed nurse is working with an experienced registered nurse. During the shift, the experienced nurse
routinely uses her personal digital assistant. How would the nurse explain theuse of this device to the novice nurse?
1. I use my PDA as a reference tool several times every day.
2. I can access my patients old medical records on this PDA.
3. I use my PDA to let the pharmacy know when I need medications.
4. I use my PDA to write nursing notes.***ANS:
1
Rationale 1: The personal digital assistant (PDA) is used to provide quick bedside information tothe nurse.
Rationale 2: The patients personal medical records would not be accessible through the PDA.Rationale 3: The
PDA would not be useful for this application.
Rationale 4: The nurse should not record nursing notes on the PDA.Global
Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
4
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