Test Bank for Priorities in Critical Care Nursing
9th Edition Urden Stacy Chapters 1–27
Complete Latest Updated
SECTION I: FOUNDATIONS OF CRITICAL CARE NURSING
Chapters 1–4
1. A nurse is caring for a patient in the intensive care unit (ICU) who was admitted with acute
respiratory distress syndrome (ARDS). The nurse recognizes that which of the following best
defines the primary goal of critical care nursing?
A. Providing curative treatment for all life-threatening conditions
B. Restoring the patient to their pre-illness level of functioning
C. Anticipating, preventing, and managing life-threatening problems
D. Reducing hospital length of stay regardless of patient outcomes
Correct Answer: C
Rationale: The primary goal of critical care nursing is to anticipate, prevent, and manage
life-threatening problems. Critical care nurses use advanced assessment skills and technology to
identify subtle changes in patient status and intervene before complications occur. Option A is
incorrect because critical care does not always cure; option B is a rehabilitation goal; option D is
an administrative outcome, not the clinical goal.
2. Which of the following patients would the nurse identify as being at highest risk for
developing a critical illness requiring ICU admission? (Select All That Apply)
A. A 72-year-old with a history of chronic obstructive pulmonary disease (COPD) and pneumonia
B. A 45-year-old with well-controlled hypertension
C. A 68-year-old with sepsis and a lactate level of 4.2 mmol/L
D. A 30-year-old with a fractured ankle
E. A 55-year-old with acute myocardial infarction and cardiogenic shock
Correct Answers: A, C, E
Rationale: Patients at highest risk for critical illness include those with compromised
physiologic reserve (elderly with COPD), those with sepsis and elevated lactate indicating tissue
,hypoperfusion, and those with acute MI complicated by cardiogenic shock. Well-controlled
hypertension (B) and a simple fracture (D) do not typically require critical care admission.
3. A nurse is discussing the concept of "failure to rescue" with a group of new graduate
nurses. Which statement by a new graduate indicates a correct understanding of this
concept?
A. "Failure to rescue refers to a patient's inability to respond to CPR."
B. "Failure to rescue is the inability of clinicians to prevent death after a treatable complication
develops."
C. "Failure to rescue means the patient was not resuscitated according to their advance
directive."
D. "Failure to rescue occurs when the pharmacy fails to deliver needed medications."
Correct Answer: B
Rationale: Failure to rescue is defined as the inability of clinicians to prevent a patient's
death after a treatable complication develops. It is often linked to inadequate monitoring,
delayed recognition of deterioration, or failure to escalate care. It is not related to CPR
response, advance directives, or pharmacy delivery.
4. The nurse is preparing to transfer a patient from the ICU to a medical-surgical unit. Which
of the following actions should the nurse take FIRST to ensure a safe transition of care?
A. Provide a complete report to the receiving nurse using a standardized handoff tool
B. Ensure the patient has a stable airway and adequate oxygenation
C. Obtain a new set of vital signs before transfer
D. Notify the family that the patient is being transferred
Correct Answer: B
Rationale: The first priority when transferring any patient is ensuring physiologic stability,
particularly airway, breathing, and circulation. While vital signs, handoff communication, and
family notification are important, they are secondary to ensuring the patient is stable enough
for transfer. This follows the ABC priority framework.
5. A nurse is assessing a patient who was just admitted to the ICU. Which of the following
findings should the nurse report to the provider IMMEDIATELY?
,A. Heart rate of 92 beats per minute
B. Blood pressure of 88/52 mmHg with a mean arterial pressure (MAP) of 64 mmHg
C. Respiratory rate of 18 breaths per minute
D. Temperature of 37.8°C (100.0°F)
Correct Answer: B
Rationale: A MAP of 64 mmHg is below the minimum threshold of 65 mmHg needed for
adequate organ perfusion. This indicates potential hypoperfusion and requires immediate
intervention. The other vital signs are within acceptable ranges for an ICU patient.
6. Which of the following best describes the role of the clinical nurse specialist (CNS) in the
critical care setting?
A. The CNS primarily performs administrative tasks and staffing assignments
B. The CNS provides direct patient care, staff education, and system-wide improvements
C. The CNS only works in outpatient settings
D. The CNS replaces the need for bedside nurses
Correct Answer: B
Rationale: The clinical nurse specialist (CNS) in critical care has a multifaceted role that
includes providing direct patient care, educating nursing staff, implementing evidence-based
practice changes, and improving system-wide processes. The CNS does not primarily perform
administrative tasks (A), is not limited to outpatient settings (C), and does not replace bedside
nurses (D).
7. A nurse is caring for a patient who has been in the ICU for 5 days. The nurse notes the
patient has developed generalized muscle weakness and difficulty weaning from the
ventilator. The nurse suspects the patient may be experiencing which condition?
A. ICU delirium
B. ICU-acquired weakness (ICU-AW)
C. Post-traumatic stress disorder (PTSD)
D. Ventilator-associated pneumonia (VAP)
Correct Answer: B
Rationale: ICU-acquired weakness (ICU-AW) is a common complication of prolonged ICU
stay, characterized by generalized muscle weakness, difficulty weaning from mechanical
, ventilation, and prolonged recovery. While ICU delirium (A) can coexist, the primary
presentation of weakness and ventilator dependence suggests ICU-AW. PTSD (C) is a
psychological condition, and VAP (D) would present with signs of infection and pulmonary
infiltrates.
8. The nurse is implementing evidence-based practices to prevent central line-associated
bloodstream infections (CLABSIs). Which of the following interventions should be included?
(Select All That Apply)
A. Hand hygiene before and after line manipulation
B. Use of maximal sterile barrier precautions during insertion
C. Routine replacement of central lines every 72 hours
D. Chlorhexidine skin antisepsis before insertion
E. Daily review of line necessity and prompt removal
Correct Answers: A, B, D, E
Rationale: CLABSI prevention bundle includes hand hygiene, maximal sterile barrier
precautions, chlorhexidine skin antisepsis, and daily review of line necessity. Routine
replacement of central lines every 72 hours (C) is NOT recommended; lines should be removed
when no longer needed, not replaced on a fixed schedule.
9. A nurse is assessing a patient's level of consciousness using the Glasgow Coma Scale (GCS).
The patient opens eyes to painful stimuli, makes incomprehensible sounds, and withdraws
from pain. What is the patient's GCS score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: C
Rationale: Eye opening to pain = 2; incomprehensible sounds = 2; withdraws from pain = 4.
Total = 2 + 2 + 4 = 8. Wait, let me recalculate: Eye opening to pain = 2, Verbal response
incomprehensible sounds = 2, Motor response withdraws from pain = 4. Total = 2+2+4 = 8.
Corrected Answer: D (8)
9th Edition Urden Stacy Chapters 1–27
Complete Latest Updated
SECTION I: FOUNDATIONS OF CRITICAL CARE NURSING
Chapters 1–4
1. A nurse is caring for a patient in the intensive care unit (ICU) who was admitted with acute
respiratory distress syndrome (ARDS). The nurse recognizes that which of the following best
defines the primary goal of critical care nursing?
A. Providing curative treatment for all life-threatening conditions
B. Restoring the patient to their pre-illness level of functioning
C. Anticipating, preventing, and managing life-threatening problems
D. Reducing hospital length of stay regardless of patient outcomes
Correct Answer: C
Rationale: The primary goal of critical care nursing is to anticipate, prevent, and manage
life-threatening problems. Critical care nurses use advanced assessment skills and technology to
identify subtle changes in patient status and intervene before complications occur. Option A is
incorrect because critical care does not always cure; option B is a rehabilitation goal; option D is
an administrative outcome, not the clinical goal.
2. Which of the following patients would the nurse identify as being at highest risk for
developing a critical illness requiring ICU admission? (Select All That Apply)
A. A 72-year-old with a history of chronic obstructive pulmonary disease (COPD) and pneumonia
B. A 45-year-old with well-controlled hypertension
C. A 68-year-old with sepsis and a lactate level of 4.2 mmol/L
D. A 30-year-old with a fractured ankle
E. A 55-year-old with acute myocardial infarction and cardiogenic shock
Correct Answers: A, C, E
Rationale: Patients at highest risk for critical illness include those with compromised
physiologic reserve (elderly with COPD), those with sepsis and elevated lactate indicating tissue
,hypoperfusion, and those with acute MI complicated by cardiogenic shock. Well-controlled
hypertension (B) and a simple fracture (D) do not typically require critical care admission.
3. A nurse is discussing the concept of "failure to rescue" with a group of new graduate
nurses. Which statement by a new graduate indicates a correct understanding of this
concept?
A. "Failure to rescue refers to a patient's inability to respond to CPR."
B. "Failure to rescue is the inability of clinicians to prevent death after a treatable complication
develops."
C. "Failure to rescue means the patient was not resuscitated according to their advance
directive."
D. "Failure to rescue occurs when the pharmacy fails to deliver needed medications."
Correct Answer: B
Rationale: Failure to rescue is defined as the inability of clinicians to prevent a patient's
death after a treatable complication develops. It is often linked to inadequate monitoring,
delayed recognition of deterioration, or failure to escalate care. It is not related to CPR
response, advance directives, or pharmacy delivery.
4. The nurse is preparing to transfer a patient from the ICU to a medical-surgical unit. Which
of the following actions should the nurse take FIRST to ensure a safe transition of care?
A. Provide a complete report to the receiving nurse using a standardized handoff tool
B. Ensure the patient has a stable airway and adequate oxygenation
C. Obtain a new set of vital signs before transfer
D. Notify the family that the patient is being transferred
Correct Answer: B
Rationale: The first priority when transferring any patient is ensuring physiologic stability,
particularly airway, breathing, and circulation. While vital signs, handoff communication, and
family notification are important, they are secondary to ensuring the patient is stable enough
for transfer. This follows the ABC priority framework.
5. A nurse is assessing a patient who was just admitted to the ICU. Which of the following
findings should the nurse report to the provider IMMEDIATELY?
,A. Heart rate of 92 beats per minute
B. Blood pressure of 88/52 mmHg with a mean arterial pressure (MAP) of 64 mmHg
C. Respiratory rate of 18 breaths per minute
D. Temperature of 37.8°C (100.0°F)
Correct Answer: B
Rationale: A MAP of 64 mmHg is below the minimum threshold of 65 mmHg needed for
adequate organ perfusion. This indicates potential hypoperfusion and requires immediate
intervention. The other vital signs are within acceptable ranges for an ICU patient.
6. Which of the following best describes the role of the clinical nurse specialist (CNS) in the
critical care setting?
A. The CNS primarily performs administrative tasks and staffing assignments
B. The CNS provides direct patient care, staff education, and system-wide improvements
C. The CNS only works in outpatient settings
D. The CNS replaces the need for bedside nurses
Correct Answer: B
Rationale: The clinical nurse specialist (CNS) in critical care has a multifaceted role that
includes providing direct patient care, educating nursing staff, implementing evidence-based
practice changes, and improving system-wide processes. The CNS does not primarily perform
administrative tasks (A), is not limited to outpatient settings (C), and does not replace bedside
nurses (D).
7. A nurse is caring for a patient who has been in the ICU for 5 days. The nurse notes the
patient has developed generalized muscle weakness and difficulty weaning from the
ventilator. The nurse suspects the patient may be experiencing which condition?
A. ICU delirium
B. ICU-acquired weakness (ICU-AW)
C. Post-traumatic stress disorder (PTSD)
D. Ventilator-associated pneumonia (VAP)
Correct Answer: B
Rationale: ICU-acquired weakness (ICU-AW) is a common complication of prolonged ICU
stay, characterized by generalized muscle weakness, difficulty weaning from mechanical
, ventilation, and prolonged recovery. While ICU delirium (A) can coexist, the primary
presentation of weakness and ventilator dependence suggests ICU-AW. PTSD (C) is a
psychological condition, and VAP (D) would present with signs of infection and pulmonary
infiltrates.
8. The nurse is implementing evidence-based practices to prevent central line-associated
bloodstream infections (CLABSIs). Which of the following interventions should be included?
(Select All That Apply)
A. Hand hygiene before and after line manipulation
B. Use of maximal sterile barrier precautions during insertion
C. Routine replacement of central lines every 72 hours
D. Chlorhexidine skin antisepsis before insertion
E. Daily review of line necessity and prompt removal
Correct Answers: A, B, D, E
Rationale: CLABSI prevention bundle includes hand hygiene, maximal sterile barrier
precautions, chlorhexidine skin antisepsis, and daily review of line necessity. Routine
replacement of central lines every 72 hours (C) is NOT recommended; lines should be removed
when no longer needed, not replaced on a fixed schedule.
9. A nurse is assessing a patient's level of consciousness using the Glasgow Coma Scale (GCS).
The patient opens eyes to painful stimuli, makes incomprehensible sounds, and withdraws
from pain. What is the patient's GCS score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: C
Rationale: Eye opening to pain = 2; incomprehensible sounds = 2; withdraws from pain = 4.
Total = 2 + 2 + 4 = 8. Wait, let me recalculate: Eye opening to pain = 2, Verbal response
incomprehensible sounds = 2, Motor response withdraws from pain = 4. Total = 2+2+4 = 8.
Corrected Answer: D (8)
