Chapter 1: High-Acuity Nursing

NCLEX-RN® Review Questions

This activity contains 10 questions.

1. A client is admitted to the IMC. His wife states that she heard on the news that IMCs with a
nurse-to-client ratio of 1:4 provide the best care. Which statement by the nurse is the best
response?

Answer: "Specific ratios are not always the best way to look at staffing."

2. After 3 days in the IMC, a client asks the nurse, "What is the difference between an RN and a
UAP? I don't understand. It seems to me like you do the same things." Which statement by the
nurse is the best response?

Answer: "UAPs are trained and supervised by nurses to complete specific care tasks."

3. What is the focus of nursing care for high-acuity clients?

Answer: Monitoring clients for subtle physiological changes

4. A high-acuity nursing unit has an "Operations Council." The members include the unit's medical
director, nurse manager, staff nurses, UAP, respiratory therapists, and a nutritionist. The Council
initiates policies and procedures, evaluates clinical care on the unit, and rewards excellence in
care. These activities reflect which AACN standards for a healthy work environment? Select all
that apply.

Answers: Meaningful recognition

Effective decision making

5. A client has become progressively sicker through the day and the UAP says, "I don't know why
they don't just move her to the ICU." Which response by the nurse caring for the client is
indicated?

Answer: "Sometimes the benefits of moving a client do not outweigh the risk involved."

6. A client is scheduled to be moved to the IMC today after 10 days in the ICU. Which occurrences
would likely prevent that move? Select all that apply.

Answers: The client became hemodynamically unstable.

The client required placement back on a mechanical ventilator.

7. A nurse who works in the ICU must constantly guard against which situation?

Answer: Becoming overly dependent upon technology

Wagner/Hardin-Pierce, High-Acuity Nursing 6e

© 2014 Pearson Education, Inc.
8. A nurse manager is concerned that nurses in the ICU may be developing burnout. Which actions
should this manager take? Select all that apply.

Answers: Keep the environment as quiet and calm as possible.

Schedule to ensure maximum rest for nurses.

Encourage good self-care among nurses.

Try to use appropriate staffing matches.

9. A laboratory technician has called the unit to report a critical lab value. What action should the
nurse take?

Answer: Write the value down and read it back to the lab tech.

10. A hospital has instituted a "blame-free" environment. What is the primary reason for this change
in policy?

Answer: So that staff will be willing to report errors

Wagner/Hardin-Pierce, High-Acuity Nursing 6e

© 2014 Pearson Education, Inc.