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Chapter 1 High-Acuity Nursing 1) 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 Answer: 1 Explanation: 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. 2. Priority 2 refers to patients who need intensive monitoring and may potentially need additional interventions. They are typically not evolving an acute event as is the case with this patient. 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. 4. Priority 4 patients have no signs or symptoms that indicate intensive monitoring or treatment are necessary. Page Ref: 2 Cognitive Level: Analyzing Client Need/Sub: Safe Effective Care Environment : Management of Care Standards: QSEN Competencies: I.A.11 Examine nursing roles in assuring coordination, integration, and continuity of care. AACN Essential Competencies: IX.11 Provide nursing care based on evidence that contributes to safe and high-quality patient outcomes within healthcare microsystems. NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. Nursing/Integ Concepts: Nursing Process: Planning LO & MNL LO: LO01: Describe the various healthcare environments in which high-acuity clients receive care.
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