NUR 425 CC exam 1 questions and answers

NUR 425: CC exam 1 questions
and answers
ICU liberation bundle - answer A : Assess, Prevent, and Manage
Pain
B : Both Spontaneous Awakening Trials (SATs) and Spontaneous
Breathing Trials (SBTs)
C : Choice of Analgesia and Sedation
D : Delirium: Assess, Prevent, and Manage
E : Early Mobility and Exercise
F : Family Engagement and Empowerment


PADIS clinical practice guidelines - answer pain
agitation/sedation
delirium
immobility
sleep disruption


CC patient - answer anxiety- r/t fear, loss of control, intense pace
and pain
communication- sedation, paralytics, ET tube, ALOC, disease process
sleep- frequent assessments and interventions in the ICU= noise,
alarms, busy units (decreased sleep leads to increased risk of
delirium)


ICU pain assessment - answer gold standard--> verbal report
inadequate pain control: agitation, anxiety, delirium, reduced
healing
nonverbal pts--> causes sympathetic response

, (we use CPOT and behavioral pain scale)


tx of pain in the ICU - answer 1. consider cause
2. positioning
2. drug and non - drug therapies


titratable Intravenous Infusions - answer - infusions must be
ordered by provider using a clear protocol with parameters
- med name and route
- starting rate
- protocol for frequency of drip rate changes
- max rate
- parameters/objective endpoint (pain goal, sedation goal, MAP)


titratable Intravenous Infusions - answer NC- documents I+Os
- use guardrails
- check med concentration
- always check math
- if you have multiple drips, which to titrate down or up 1st
-


CPOT - answer - assesses pain
- fentanyl/morphine
- scale 5-6 ( patient's pain is uncontrolled)
- scale 2- patient's pain is control and they are comfortable


RASS - answer - sedation
- -1 : slightly sedated