NR 341 Final Exam 2022 Questions and Answers- Chamberlain College of Nursing
Nr 341 Final
Exam 2022
Which of the following professional organizations
... [Show More] best supports critical care
nursing practice?
a. American Association of Critical-Care Nurses
b. American Heart Association
c. American Nurses Association
d. Society of Critical Care Medicine -ANS a
The synergy model of practice focuses on:
a. allowing unrestricted visiting for the patient 24 hours each day.
b. holistic and alternative therapies.
c. needs of patients and their families, which drives nursing competency.
d. patients' needs for energy and support. -ANS c
The family of your critically ill patient tells you that they have not spoken
with the physician in over 24 hours and they have some questions that they
want clarified. During morning rounds, you convey this concern to the
attending intensivist and arrange for her to meet with the family at 4:00 PM
in the conference room. Which competency of critical care nursing does this
represent?
a. Advocacy and moral agency in solving ethical issues
b. Clinical judgment and clinical reasoning skills
c. Collaboration with patients, families, and team members
d. Facilitation of learning for patients, families, and team members -ANS c
The charge nurse is responsible for making the patient assignments on the
critical care unit. She assigns the experienced, certified nurse to care for the
acutely ill patient with sepsis who also requires continuous renal replacement
therapy and mechanical ventilation. She assigns the nurse with less than 1
year of experience to two patients who are more stable. This assignment
reflects implementation of the:
a. crew resource management model
b. National Patient Safety Goals
c. Quality and Safety Education for Nurses (QSEN) model
d. synergy model of practice -ANS d
The family members of a critically ill, 90-year-old patient bring in a copy of
the patient's living will to the hospital, which identifies the patient's wishes
regarding health care. You discuss contents of the living will with the
patient's physician. This is an example of implementation of which of the
AACN Standards of Professional Performance?
a. Acquires and maintains current knowledge of practice
b. Acts ethically on the behalf of the patient and family
c. Considers factors related to safe patient care
d. Uses clinical inquiry and integrates research findings in practice -ANS b
As part of nursing management of a critically ill patient, orders are written to
keep the head of the bed elevated at 30 degrees, awaken the patient from
sedation each morning to assess readiness to wean from mechanical
ventilation, and implement oral care protocols every 4 hours. These
interventions are done as a group to reduce the risk of ventilator-associated
pneumonia. This group of evidence-based interventions is often called a:
a. bundle of care.
b. clinical practice guideline.
c. patient safety goal.
d. quality improvement initiative. -ANS a
Which of the following statements describes the core concept of the synergy
model of practice?
a. All nurses must be certified in order to have the synergy model
implemented.
b. Family members must be included in daily interdisciplinary rounds.
c. Nurses and physicians must work collaboratively and synergistically to
influence care.
d. Unique needs of patients and their families influence nursing
competencies. -ANS d
Which of the following is a National Patient Safety Goal? (Select all that
apply.)
a. Accurately identify patients.
b. Eliminate use of patient restraints.
c. Reconcile medications across the continuum of care.
d. Reduce risks of healthcare-acquired infection. -ANS a,c,d
Which of the following nursing activities demonstrates implementation of the
AACN Standards of Professional Performance? (Select all that apply.)
a. Attending a meeting of the local chapter of the American Association of
Critical-Care Nurses in which a continuing education program on sepsis is
being taught
b. Collaborating with a pastoral services colleague to assist in meeting
spiritual needs of the patient and family
c. Participating on the unit's nurse practice council
d. Posting an article from Critical Care Nurse on management of venous
thromboembolism for your colleagues to read
e. Using evidence-based strategies to prevent ventilator-associated
pneumonia -ANS a,b,c,d,e
Which scenarios contribute to effective handoff communication at change of
shift? (Select all that apply.)
a. The nephrology consultant physician is making rounds and asks you to
update her on the patient's status and assist in placing a central line for
hemodialysis.
b. The noise level is high because twice as many staff members are present
and everyone is giving report in the nurse's station.
c. The unit has decided to use a standardized checklist/tool for change-ofshift reports and patient transfers.
d. You and the oncoming nurse conduct a standardized report at the patient's
bedside and review key assessment findings. -ANS c,d
Which strategy is important to addressing issues associated with the aging
workforce? (Select all that apply.)
a. Allowing nurses to work flexible shift durations
b. Encouraging older nurses to transfer to an outpatient setting that is less
stressful
c. Hiring nurse technicians that are available to assist with patient care, such
as turning the patient
d. Remodeling patient care rooms to include devices to assist in patient
lifting -ANS a,c,d
Which of the following strategies will assist in creating a healthy work
environment for the critical care nurse? (Select all that apply.)
a. Celebrating improved outcomes from a nurse-driven protocol with a pizza
party
b. Implementing a medication safety program designed by pharmacists
c. Modifying the staffing pattern to ensure a 1:1 nurse/patient ratio
d. Offering quarterly joint nurse-physician workshops to discuss unit issues
e. Using the Situation-Background-Assessment-Recommendation (SBAR)
technique for handoff communication -ANS a,d,e
The nurse is caring for a patient who is on a cardiac monitor. The nurse
realizes that the sinus node is the pacemaker of the heart because it is:
a. the fastest pacemaker cell in the heart.
b. the only pacemaker cell in the heart.
c. the only cell that does not affect the cardiac cycle.
d. located in the left side of the heart. -ANS A
The cardiac cycle begins with an impulse that is generated from a small
concentrated area of pacemaker cells high in the right atria called the
sinoatrial node (sinus node or SA node). The SA node has the fastest rate of
discharge and thus is the dominant pacemaker of the heart. The AV node has
pacemaker properties and can discharge an impulse if the SA node fails. The
ventricles have pacemaker capabilities if the sinus node or the AV node
ceases to generate impulses.
One of the functions of the atrioventricular (AV) node is to:
a. pace the heart if the ventricles fail.
b. slow the impulse arriving from the SA node.
c. send the impulse to the SA node.
d. allow for ventricular filling during systole. -ANS b
The normal rate for the SA node when the patient is at rest is:
a. 40 to 60 beats per minute.
b. 60 to 100 beats per minute.
c. 20 to 40 beats per minute.
d. more than100 beats per minute. -ANS b
When assessing the 12-lead electrocardiogram (ECG) or a rhythm strip, it is
helpful to understand that the electrical activity is viewed in relation to the
positive electrode of that particular lead. When an electrical signal is aimed
directly at the positive electrode, the inflection will be:
a. negative.
b. upside down.
c. upright.
d. equally positive and negative. -ANS c
The nurse is examining the patient's cardiac rhythm strip in lead II and
notices that all of the P waves are upright and look the same except one that
has a different shape and is inverted. The nurse realizes that the P wave with
the abnormal shape is probably:
a. from the SA node since all P waves come from the SA node.
b. from some area in the atria other than the SA node.
c. indicative of ventricular depolarization.
d. normal even though it is inverted in lead II. -ANS b
Normally a P wave indicates that the SA node initiated the impulse that
depolarized the atrium. However, a change in the shape of the P wave may
indicate that the impulse arose from a site in the atria other than the SA
node. The P wave represents atrial depolarization. It is usually upright in
leads I and II and has a rounded, symmetrical shape. The amplitude of the P
wave is measured at the center of the waveform and normally does not
exceed three boxes, or 3 millimeters, in height.
The QT interval is the total time taken for ventricular depolarization and
repolarization. Prolongation of the QT interval:
a. decreases the risk of lethal dysrhythmias.
b. usually occurs when heart rate increases.
c. increases the risk of lethal dysrhythmias.
d. can only be measured with irregular rhythms. -ANS c
The patient has an irregular heart rhythm. To determine an accurate heart
rate, the nurse first:
a. identifies the markers on the ECG paper that indicate a 6-second strip.
b. counts the number of large boxes between two consecutive P waves.
c. counts the number of small boxes between two consecutive QRS
complexes.
d. divides the number of complexes in a 6-second strip by 10. -ANS A
Six-second method: A quick and easy estimate of heart rate can be
accomplished by counting the number of P waves or QRS waves within a 6-
second strip to obtain atrial and ventricular heart rates per minute. This is
the optimal method for irregular rhythms. Identify the lines above the ECG
paper that represent 6 seconds, and count the number of P waves within the
lines; then add a zero (multiply by 10) to identify the atrial heart rate
estimate for 1 minute. Next, identify the number of QRS waves in the 6-
second strip and again add a zero to identify the ventricular rate.
The nurse is calculating the rate for a regular rhythm. There are 20 small
boxes between each P wave and 20 small boxes between each R wave. What
is the ventricular rate?
a. 50 beats/min
b. 75 beats/min
c. 85 beats/min
d. 100 beats/min -ANS B
The rule of 1500 is used to calculate the exact rate of a regular rhythm. The
number of small boxes between the highest points of two consecutive R
waves is counted, and that number of small boxes is divided into 1500 to
determine the ventricular rate. 1500/20 = 75 beats/min. This method is
accurate only if the rhythm is regular
The patient is admitted with a fever and rapid heart rate. The patient's
temperature is 103° F (39.4° C).The nurse places the patient on a cardiac
monitor and finds the patient's atrial and ventricular rates are above 105
beats per minute. P waves are clearly seen and appear normal in
configuration. QRS complexes are normal in appearance and 0.08 seconds
wide. The rhythm is regular, and blood pressure is normal. The nurse should
focus on providing:
a. medications to lower heart rate.
b. treatment to lower temperature.
c. treatment to lower cardiac output.
d. treatment to reduce heart rate. -ANS B
Sinus tachycardia results when the SA node fires faster than 100 beats per
minute. Sinus tachycardia is a normal response to stimulation of the
sympathetic nervous system. Sinus tachycardia is also a normal finding in
children younger than 6 years. Both atrial and ventricular rates are greater
than 100 beats per minute, up to 160 beats per minute, but may be as high
as 180 beats per minute. Sinus tachycardia is regular or essentially regular.
PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P
and QRS waves are consistent in shape. P waves are small and rounded. A P
wave precedes every QRS complex, which is then followed by a T wave.
Which of the following is true about a patient diagnosed with sinus
arrhythmia?
a. The heart rate varies, dependent on vagal tone and respiratory pattern.
b. Immediate treatment is essential to prevent death.
c. Sinus arrhythmia is not well tolerated by most patients.
d. PR and QRS interval measurements are prolonged. -ANS A
Sinus arrhythmia is a cyclical change in heart rate that is associated with
respiration. The heart rate increases slightly during inspiration and slows
slightly during exhalation because of changes in vagal tone. The ECG tracing
demonstrates an alternating pattern of faster and slower heart rate that
changes with the respiratory cycle.
The patient is admitted with sinus pauses causing periods of loss of
consciousness. The patient is asymptomatic, awake and alert, but fatigued.
He answers questions appropriately. When admitting this patient, the nurse
should first:
a. prepare the patient for temporary pacemaker insertion.
b. prepare the patient for permanent pacemaker insertion.
c. assess the patient's medication profile.
d. apply transcutaneous pacemaker paddles. -ANS c
The patient's heart rate is 165 beats per minute. His cardiac monitor shows a
rapid rate with narrow QRS complexes. The P waves cannot be seen, but the
rhythm is regular. The patient's blood pressure has dropped from 124/62 to
78/30. His skin is cold and diaphoretic and he is complaining of nausea. The
nurse prepares the patient for:
a. administration of beta-blockers.
b. administration of atropine.
c. transcutaneous pacemaker insertion.
d. emergent cardioversion. -ANS D
If an abnormal P wave cannot be visualized on the ECG but the QRS complex
is narrow, the term supraventricular tachycardia (SVT) is often used. This is a
generic term that describes any tachycardia that is not ventricular in origin;
it is also used when the source above the ventricles cannot be identified,
usually because the rate is too fast. Treatment is directed at assessing the
patient's tolerance of the tachycardia. If the rate is higher than 150 beats per
minute and the patient is symptomatic, emergent cardioversion is
considered. Cardioversion is the delivery of a synchronized electrical shock
to the heart by an external defibrillator.
The nurse is reading the cardiac monitor and notes that the patient's heart
rhythm is extremely irregular and there are no discernible P waves. The
ventricular rate is 90 beats per minute, and the patient is hemodynamically
stable. The nurse realizes that the patient's rhythm is:
a. atrial fibrillation.
b. atrial flutter.
c. atrial flutter with rapid ventricular response.
d. junctional escape rhythm. -ANS a
The patient's heart rhythm shows an inverted P wave with a PR interval of
0.06 seconds. The heart rate is 54 beats per minute. The nurse recognizes
the rhythm as a junctional escape rhythm, and understands that the rhythm
is due to the:
a. loss of sinus node activity.
b. increased rate of the AV node.
c. increased rate of the SA node.
d. decreased rate of the AV node. -ANS a
-ANS
The patient's heart rate is 70 beats per minute, but the P waves come after
the QRS complex. The nurse correctly determines that the patient's heart
rhythm is:
a. a normal junctional rhythm.
b. an accelerated junctional rhythm.
c. a junctional tachycardia.
d. atrial fibrillation. -ANS b
The normal intrinsic rate for the AV node and junctional tissue is 40 to 60
beats per minute, but rates can accelerate. An accelerated junctional rhythm
has a rate between 60 and 100 beats per minute, and the rate for junctional
tachycardia is greater than 100 beats per minute.
The patient is having premature ventricular contractions (PVCs). The nurse's
greatest concern should be:
a. the proximity of the R wave of the PVC to the T wave of a normal beat.
b. the fact that PVCs are occurring, because they are so rare.
c. if the number of PVCs are decreasing.
d. if the PVCs are wider than 0.12 seconds. -ANS a
The nurse notices that the patient has a first-degree AV block. Everything
else about the rhythm is normal. The nurse should:
a. prepare to place the patient on a transcutaneous pacemaker.
b. give the patient atropine to shorten the PR interval.
c. monitor the rhythm and patient's condition.
d. give the patient an antiarrhythmic medication. -ANS C
First-degree AV block is a common dysrhythmia in the elderly and in patients
with cardiac disease. As the normal conduction pathway ages or becomes
diseased, impulse conduction becomes slower than normal. It is well
tolerated. No treatment is required. Continue to monitor the patient and the
rhythm.
The nurse understands that in a third-degree AV block:
a. every P wave is conducted to the ventricles.
b. some P waves are conducted to the ventricles.
c. none of the P waves are conducted to the ventricles.
d. the PR interval is prolonged. -ANS C
In first-degree AV block, a P wave precedes every QRS complex, which is
followed by a T wave indicating complete conduction. It is represented on the
ECG as a prolonged PR interval. Second-degree heart block refers to AV
conduction that is intermittently blocked. Therefore, some P waves are
conducted and some are not. Third-degree block is often called complete
heart block because no atrial impulses are conducted through the AV node to
the ventricles.
The patient is asymptomatic but is diagnosed with second-degree heart
block Mobitz I. The patient is on digitalis medication at home. The nurse
should expect that:
a. the patient has had an anterior wall myocardial infarction.
b. the physician will order the digitalis to be continued in the hospital.
c. a digitalis level would be ordered upon admission.
d. the patient will require a transcutaneous pacemaker. -ANS C
Digitalis toxicity is a major cause of this rhythm, and further digitalis doses
should not be given until a digitalis level is obtained. Other causes of Mobitz I
include AV nodal blocking drugs, acute inferior wall myocardial infarction or
right ventricular infarction, ischemic heart disease, and excess vagal
response. This type of block is usually well tolerated and no treatment is
indicated unless the dropped beats occur frequently.
The patient has a permanent pacemaker inserted. The provider has set the
pacemaker to the demand mode at a rate of 60 beats per minute. The nurse
realizes that:
a. the pacemaker will pace only if the patient's intrinsic heart rate is less
than 60 beats per minute.
b. the demand mode often competes with the patient's own rhythm.
c. the demand mode places the patient at risk for the R-on-T phenomenon.
d. the fixed rate mode is safer and is the mode of choice. -ANS A
Pacemakers can be operated in a demand mode or a fixed rate
(asynchronous) mode. The demand mode paces the heart when no intrinsic
or native beat is sensed. For example, if the rate control is set at 60 beats
per minute, the pacemaker will only pace if the patient's heart rate drops to
less than 60. The fixed rate mode paces the heart at a set rate, independent
of any activity the patient's heart generates. The fixed rate mode may
compete with the patient's own rhythm and deliver an impulse on the T wave
(R-on-T phenomenon), with the potential for producing ventricular
tachycardia or fibrillation. The demand mode is safer and is the mode of
choice.
The rhythm on the cardiac monitor is showing numerous pacemaker spikes,
but no P waves or QRS complexes following the spikes. The nurse realizes
this as:
a. normal pacemaker function.
b. failure to capture.
c. failure to pace.
d. failure to sense. -ANS B
When the pacemaker generates an electrical impulse (pacer spike) and no
depolarization is noted, it is described a failure to capture. On the ECG, a
pacer spike is noted, but it is not followed by a P wave (atrial pacemaker) or
a QRS complex (ventricular pacemaker). Common causes of failure to
capture include output (milliamperes) set too low, or displacement of the
pacing lead wire from the myocardium (transvenous or epicardial leads).
Other causes of failure to capture include battery failure, fracture of the
pacemaker wire, or increased pacing threshold as a result of medication or
electrolyte imbalance. This is not normal pacemaker function.
Normal sinus rhythm -ANS
ventricular tachycardia -ANS
Sinus Tachycardia -ANS
Sinus Bradycardia -ANS
Ventricular fibrillation -ANS
Atrial fibrillation -ANS
Junctional rhythm -ANS
Sinus rhythm with multifocal premature ventricular contractions -ANS
unifocal premature ventricular contractions -ANS
bigeminal premature ventricular contractions -ANS
paired premature ventricular contractions (couplets) -ANS
R-on-T phenomenon -ANS
Idioventricular rhythm -ANS
first-degree AV block -ANS
Second-degree AVB Mobitz I -ANS
Second-degree AVB Mobitz II -ANS
Third-degree AVB (complete heart block) -ANS
Atrial pacing -ANS
Ventricular pacing -ANS
Dual-chamber pacing -ANS
Failure to pace -ANS
Failure to sense -ANS
The normal width of the QRS complex is which of the following? (Select all
that apply.)
a. 0.06 to 0.10 seconds.
b. 0.12 to 0.20 seconds.
c. 1.5 to 2.5 small boxes.
d. 3.0 to 5.0 small boxes.
e. 0.04 seconds or greater. -ANS a,c
Which of the following are common causes of sinus tachycardia? (Select all
that apply.)
a. Hyperthyroidism
b. Hypovolemia
c. Hypothyroidism
d. Heart Failure
e. Sleep -ANS a,b,d
Sinus bradycardia is a symptom of which of the following? (Select all that
apply.)
a. Calcium channel blocker medication
b. Beta-blocker medication
c. Athletic conditioning
d. Hypothermia
e. Hyperthyroidism -ANS a,b,c,d
The nurse is caring for a patient who has atrial fibrillation. Sequelae that
place the patient at greater risk for mortality/morbidity include which of the
following? (Select all that apply.)
a. Stroke
b. Ashman beats
c. Pulmonary emboli
d. Prolonged PR interval
e. Decreased cardiac output -ANS a,c,e
The patient is in third-degree heart block (complete heart block) and is
symptomatic. The treatment for this patient is which of the following? (Select
all that apply.)
a. transcutaneous pacemaker.
b. atropine IV.
c. temporary transvenous pacemaker.
d. permanent pacemaker.
e. amiodarone IV. -ANS a,c,d
Because of the location of the AV node, the possible P waveforms that are
associated with junctional rhythms include which of the following? (Select all
that apply.)
a. No P wave
b. Inverted P wave
c. Shortened PR interval
d. P wave after the QRS complex
e. Normal P wave and PR interval -ANS a,b,c,d
Patient has V-tach and and BP of 90/44 -ANS treat with intravenous
amiodarone or lidocaine
V- Fib -ANS Provide basic and advanced life support
A patient who is undergoing withdrawal of mechanical ventilation appears
anxious and agitated. The patient is on a continuous morphine infusion and
has an additional order for lorazepam (Ativan) 1 to 2 mg IV as needed (prn).
The patient has received no lorazepam (Ativan) during this course of illness.
What is the most appropriate nursing intervention to control agitation?
a. Administer fentanyl (Duragesic) 25 mg IV bolus.
b. Administer lorazepam (Ativan) 1 mg IV now.
c. Increase the rate of the morphine infusion by 50%.
d. Request an order for a paralytic agent. -ANS B
Lorazepam (Ativan) 1 mg IV is an appropriate loading dose for a patient who
is benzodiazepine naïve and experiencing agitation during withdrawal of life
support. Fentanyl treats pain and morphine controls pain. Paralytic agents
are not warranted.
What were the findings of the Study to Understand Prognoses and
Preferences for Outcomes and Risks of Treatment (SUPPORT)?
a. Clear communication is typical in the relationships between most patients
and healthcare providers.
b. Critical care units often meet the needs of dying patients and their
families.
c. Disparities exist between patients' care preferences and actual care
provided.
d. Pain and suffering of patients at end of life is well controlled in the
hospital. -ANS c
A statement that provides a legally recognized description of an individual's
desires regarding care at the end of life is a (an):
a. advance directive.
b. guardianship ad litem.
c. healthcare proxy.
d. power of attorney. -ANS a
A 65-year-old patient with a history of metastatic lung carcinoma has been
unresponsive to chemotherapy. The medical team has determined that there
are no additional treatments available that will prolong life or improve the
quality of life in any meaningful way. Despite the poor prognosis, the patient
continues to receive chemotherapy and full nutrition support. This is an
example of what end-of-life concept?
a. Medical futility
b. Palliative care
c. Terminal weaning
d. Withdrawal of treatment -ANS A
Medical futility is a situation in which therapy or interventions will not
provide a foreseeable possibility of improvement in the patient's health
status.
Which statement made by a staff nurse identifying guidelines for palliative
care would need corrected?
a. Basic nursing care is a critical element in palliative care management.
b. Common conditions that require palliative management are nausea,
agitation, and sleep disturbance.
c. Palliative care practices are reserved for the dying client.
d. Palliative care practices relieve symptoms that negatively affect the
quality of life of a patient. -ANS C
The purpose of palliative care is to relieve negative symptoms that affect the
quality of life of a patient. Palliative care is an integral part of every injured
or ill patient's care. Basic nursing care, including repositioning, skin care, and
provision of a peaceful environment, promote comfort. These conditions all
commonly require palliative care techniques.
The most critical element of effective early end-of-life decision making is:
a. control of distressing symptoms such as nausea, anxiety, and pain.
b. effective communication between the patient, family, and healthcare team
throughout the course of the illness.
c. organizational support of palliative care principles.
d. relocation the dying patient from the critical care unit to a lower level of
care. -ANS b
A patient with end-stage heart failure is experiencing considerable dyspnea.
Appropriate pharmacological management of this symptom includes:
a. administration of 6 mg of midazolam (Versed) and initiation of a
continuous midazolam infusion.
b. administration of morphine, 5 mg IV bolus, and initiation of a continuous
morphine infusion.
c. hourly increases of the midazolam (Versed) infusion by 100% dose
increments.
d. hourly increases of the morphine infusion by 100% dose increments. -ANS
b
The family is considering withdrawing life-sustaining measures from the
patient. The nurse knows that ethical principles for withholding or
withdrawing life-sustaining treatments include which of the following?
a. Any treatment may be withdrawn and withheld, including nutrition,
antibiotics, and blood products.
b. Doses of analgesic and anxiolytic medications must be adjusted carefully
and should not exceed usual recommended limits.
c. Life-sustaining treatments may be withdrawn while a patient is receiving
paralytic agents.
d. The goal of withdrawal and withholding of treatments is to hasten death
and thus relieve suffering. -ANS a
To prevent any unwanted resuscitation after life-sustaining treatments have
been withdrawn, the nurse should ensure that:
a. do-not-resuscitate (DNR) orders are written before discontinuation of the
treatments.
b. the family is not allowed to visit until the death occurs.
c. DNR orders are written as soon as possible after the discontinuation of the
treatments.
d. the change-of-shift report includes the information that the patient is not
to be resuscitated. -ANS a
Which of the following statements about comfort care is accurate?
a. Withholding and withdrawing life-sustaining treatment are distinctly
different in the eyes of the legal community.
b. Each procedure should be evaluated for its effect on the patient's comfort
before being implemented.
c. Only the patient can determine what constitutes comfort care for him or
her.
d. Withdrawing life-sustaining treatments is considered euthanasia in most
states. -ANS b
Select interventions that may be included during "terminal weaning" include
which of the following? (Select all that apply.)
a. Complete extubation following ventilator withdrawal
b. Discontinuation of artificial ventilation but maintenance of the artificial
airway
c. Discontinuation of anxiolytic and pain medications
d. Titration of ventilator support based upon blood gas determinations
e. Titration of ventilator support to minimal levels based upon patient
assessment of comfort -ANS a,b,e
Palliation may include: (Select all that apply.)
a. relieving pain.
b. relieving nausea.
c. psychological support.
d. withdrawing life-support interventions.
e. withholding tube feedings. -ANS a,b,c
Nociceptors differ from other nerve receptors in the body in that they:
a. adapt very little to continual pain response.
b. inhibit the infiltration of neutrophils and eosinophils.
c. play no role in the inflammatory response.
d. transmit only the thermal stimuli. -ANS A
Nociceptors are stimulated by mechanical, chemical, or thermal stimuli.
Nociceptors differ from other nerve receptors in the body in that they adapt
very little to the pain response.
A 45-year-old male postsurgical patient is on a ventilator in the critical care
unit. He has been tolerating the ventilator well and has not required any
sedation. He becomes tachycardic and hypertensive. His respiratory rate has
increased to 28 breaths/min. The ventilator is set on synchronized
intermittent mandatory ventilation (SIMV) at a rate of 10 breaths/min. The
patient has been suctioned recently via his endotracheal tube, and his
airway is clear. He responds appropriately to the nurse's commands. The
nurse should:
a. assess the patient's level of pain.
b. decrease the SIMV rate on the ventilator.
c. provide sedation as ordered.
d. suction the patient again. -ANS a
Both the electroencephalogram (EEG) monitor and the Bispectral Index Score
(BIS) or Patient State Index (PSI) analyzer monitors are used to assess
patient sedation levels in critically ill patients. The BIS and PSI monitors are
simpler to use because they:
a. can only be used on heavily sedated patients.
b. can only be used on pediatric patients.
c. provide raw EEG data and a numeric value.
d. require only five leads. -ANS c
The nurse is caring for a patient who requires administration of a
neuromuscular blocking agent to facilitate ventilation with non-traditional
modes. The nurse understands that neuromuscular blocking agents provide:
a. antianxiety effects.
b. complete analgesia.
c. high levels of sedation.
d. no sedation or analgesia. -ANS D
Neuromuscular blocking (NMB) agents do not possess any sedative or
analgesic properties. Patients who receive NMBs must also receive a sedative
agent.
The patient is receiving neuromuscular blockade. Which nursing assessment
indicates a target level of paralysis?
a. Glasgow Coma Scale score of 3
b. Train-of-four yields two twitches
c. Bispectral index of 60
d. CAM-ICU positive -ANS B
A train-of-four response of two twitches using a peripheral nerve stimulator
indicates adequate paralysis. The Glasgow Coma Scale does not assess
paralysis; it is an indicator of consciousness. The Bispectral Index provides
an assessment of sedation. The CAM-ICU is a tool to assess delirium
The most important nursing intervention for patients who receive
neuromuscular blocking agents is to:
a. administer sedatives in conjunction with the neuromuscular blocking
agents.
b. assess neurological status every 30 minutes.
c. avoid interaction with the patient, because he or she won't be able to hear.
d. restrain the patient to avoid self-extubation. -ANS a
The best way to monitor agitation and effectiveness of treating it in the
critically ill patient is to use a/the:
a. Confusion Assessment Method (CAM-ICU).
b. FACES assessment tool.
c. Glasgow Coma Scale.
d. scale such as Richmond Agitation Sedation Scale. -ANS D
The nurse is caring for a patient receiving intravenous ibuprofen for pain
management. The nurse recognizes which laboratory assessment to be a
possible side effect of the ibuprofen?
a. Elevated creatinine
b. Elevated platelet count
c. Elevated white blood count
d. Low liver enzymes -ANS A
Ibuprofen can result in renal insufficiency, which may be noted in an elevated
serum creatinine level.
The nurse wishes to assess the quality of a patient's pain. Which of the
following questions is appropriate to obtain this assessment if the patient is
able to give a verbal response?
a. "Is the pain constant or intermittent?"
b. "Is the pain sharp, dull, or crushing?"
c. "What makes the pain better? Worse?"
d. "When did the pain start?" -ANS b
The nurse is assessing the patient's pain using the Critical Care Pain
Observation Tool. Which of the following assessments would indicate the
greatest likelihood of pain and need for nursing intervention?
a. Absence of vocal sounds
b. Fighting the ventilator
c. Moving legs in bed
d. Relaxed muscles in upper extremities -ANS B
Fighting the ventilator is rated with the greatest number of points for
compliance with the ventilator, and could indicate pain or anxiety.
The nurse is caring for a patient receiving benzodiazepine intermittently. The
nurse understands that the best way to administer such drugs is to:
a. administer around the clock, rather than as needed, to ensure constant
sedation.
b. administer the medications through the feeding tube to prevent
complications.
c. give the highest allowable dose for the greatest effect.
d. titrate to a predefined endpoint using a standard sedation scale. -ANS d
Which of the following statements regarding pain and anxiety are true?
(Select all that apply.)
a. Anxiety is a state marked by apprehension, agitation, autonomic arousal,
and/or fearful withdrawal.
b. Critically ill patients often experience anxiety, but they rarely experience
pain.
c. Pain and anxiety are often interrelated and may be difficult to differentiate
because their physiological and behavioral manifestations are similar.
d. Pain is defined by each patient; it is whatever the person experiencing the
pain says it is. -ANS a,c,d
Choose the items that are common to both pain and anxiety. (Select all that
apply.)
a. Cyclical exacerbation of one another
b. Require good nursing assessment for proper treatment
c. Response only to real phenomena
d. Subjective in nature -ANS a,b,d
Anxiety differs from pain in that: (Select all that apply.)
a. it is confined to neurological processes in the brain.
b. it is linked to reward and punishment centers in the limbic system.
c. it is subjective.
d. there is no actual tissue injury. -ANS a,b,d
In the healthy individual, pain and anxiety: (Select all that apply.)
a. activate the sympathetic nervous system.
b. decrease stress levels.
c. help remove one from harm.
d. increase performance levels. -ANS a,c,d
The nurse is caring for a 48-year-old patient who is intubated and on a
ventilator following extensive abdominal surgery. Although the patient is
responsive, the nurse is not able to read the patient's lips as the patient
attempts to mouth the words. Which of the following assessment tools would
be the most appropriate for the nurse to use when assessing the patient's
pain level? (Select all that apply.)
a. The FACES scale
b. Pain IntensityScale
c. The PQRST method
d. The Visual Analogue Scale -ANS a,d
In the critically ill patient, an incomplete assessment and/or management of
pain or anxiety may be hampered by which of the following? (Select all that
apply.)
a. Administration of neuromuscular blocking agents
b. Delirium
c. Effective nurse communication and assessment skills
d. Nonverbal patients -ANS a,b,d
The nurse is caring for a postoperative patient in the critical care unit. The
physician has ordered patient-controlled analgesia (PCA) for the patient. The
nurse understands that the PCA: (Select all that apply.)
a. is a safe and effective method for administering analgesia.
b. has potentially fewer side effects than other routes of analgesic
administration.
c. is an ideal method to provide critically ill patients some control over their
treatment.
d. provides good quality analgesia. -ANS a,b,d
A patient requires neuromuscular blockade (NMB) as part of treatment of
refractive increased intracranial pressure. The nursing care for this patient
includes: (Select all that apply.)
a. administration of sedatives concurrently with neuromuscular blockade.
b. dangling the patient's feet over the edge of the bed and assisting the
patient to sit up in a chair at least twice each day.
c. ensuring that deep vein thrombosis prophylaxis is initiated.
d. providing interventions for eye care, oral care, and skin care. -ANS a,c,d
The nurse is assessing the critically ill patient for delirium. The nurse
recognizes which characteristics that indicate hyperactive delirium? (Select
all that apply.)
a. Agitation
b. Apathy
c. Biting
d. Hitting
e. Restlessness -ANS a,c,d,e [Show Less]