Essentials of Critical Care Nursing Ch. 1& 2 Exam
Revision Questions and Verified A+ Answers
The nurse identifies a patient in the critical care unit as having "resiliency." What characteristic has the
nurse identified in the patient?
1. Motivation to reduce anxiety through positive self-talk
2. Ability to bounce back quickly after an insult
3. Physical strength to endure extreme physical stressors
4. Ability to return to a state of equilibrium - Answer 2
The nurse realizes that which stressor is one of the primary concerns of critically ill patients and should
be routinely included during assessments?
1. Inability to control elimination
2. Lack of family support
3. Hunger
4. Altered ability to communicate - Answer 4
A patient has just completed a preoperative education session prior to undergoing coronary artery
bypass surgery. Which patient statements indicate that teaching has been effective?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. "I understand that I will have to blink my eyes to respond after the breathing tube is in my throat."
2. "I will be given frequent mouth care to help me when I am thirsty."
3. "I will be able to move about freely in bed and into the chair without help while connected to the
electronic equipment for monitoring."
4. "I may need something to help me rest due to the unfamiliar lights and sounds of the ICU unit."
5. "I might not behave like my usual self after the surgery but it will be because of the medications and
my illness." - Answer 1,2,4,5
When providing care to critically ill patients, whether they are responsive or unresponsive, the nurse
should:
,1. Clearly explain what care is to be done before starting the activity.
2. Perform the activity and then let the patient rest without explaining the care.
3. Make sure the patient always responds and is cooperative before giving care.
4. Explain to the family that the patient will not understand or remember any of the discomfort
associated with care. - Answer 1
Which communication strategy is most appropriate for a critical care nurse to use when communicating
with a ventilated patient? The nurse should:
1. Use professional terminology and provide the patient with detailed information.
2. Use simple language and explain in other terms if the patient does not seem to understand.
3. Provide minimal information so the patient is not overwhelmed.
4. Discuss issues primarily with the family because the patient is unlikely to understand the information.
- Answer 2
During an assessment, a ventilated patient begins to frown and wiggle about in bed. Which assessment
strategy would be most helpful for the nurse to validate these observations?
1. Glasgow Scale
2. Maslow's hierarchy levels
3. Critical-Care Pain Observation Tool (CPOT)
4. Vital signs trends - Answer 3
Which parameters indicate that a patient in the intensive care unit being mechanically ventilated is
ready for an interruption in sedation? The patient:
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Had a MAP of 75 and heart rate of 76
2. Was sleeping but awakened with verbal stimuli
3. Frowned when turned but otherwise showed no muscular tension
4. Activated the ventilator alarms but the alarms stopped spontaneously
5. Is receiving neuromuscular blocking agents to ensure adequate ventilation - Answer 1,2,3,4
, A patient scores positive on the Confusion Assessment Method of the Intensive Care Unit (CAM-ICU).
Which nursing diagnosis would have the highest priority based on this positive score?
1. Injury, Risk for
2. Family Processes, Altered
3. Social Interaction, Impaired
4. Memory Impaired - Answer 1
Which nursing actions would be appropriate when a nurse is initiating an infusion of morphine sulfate
for a post-operative patient who is experiencing pain?
1. Anticipate that the patient will begin to experience the effect of the morphine 15 minutes after the
start of the infusion.
2. Provide additional intermittent boluses of morphine sulfate if the patient experiences breakthrough
pain.
3. Complete the Critical-Care Pain Observation Tool scale 5 minutes after increasing the infusion rate
each time.
4. Begin the infusion at the lowest ordered dose and increase the rate every 30 minutes if the patient
continues to have pain. - Answer 2
Which strategies should the nurse include in the plan of care when trying to minimize sleep disruptions
for a patient in an ICU?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Instituting a short course of therapy for sleeping agents
2. Accurate scoring and vigilance in sedation and sedation scoring
3. Managing the environment to reduce lighting, sounds, and so on
4. Minimizing staff interruptions during sleep periods
5. Scheduling treatments only during the day or at least 4 hours apart at night - Answer 1,2,3,4
A nurse is confirming the medication orders and schedule for sedative administration to a patient with
delirium. Which schedule would maximize the effectiveness of the drugs? Administration of medication:
1. Only in the early morning
Revision Questions and Verified A+ Answers
The nurse identifies a patient in the critical care unit as having "resiliency." What characteristic has the
nurse identified in the patient?
1. Motivation to reduce anxiety through positive self-talk
2. Ability to bounce back quickly after an insult
3. Physical strength to endure extreme physical stressors
4. Ability to return to a state of equilibrium - Answer 2
The nurse realizes that which stressor is one of the primary concerns of critically ill patients and should
be routinely included during assessments?
1. Inability to control elimination
2. Lack of family support
3. Hunger
4. Altered ability to communicate - Answer 4
A patient has just completed a preoperative education session prior to undergoing coronary artery
bypass surgery. Which patient statements indicate that teaching has been effective?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. "I understand that I will have to blink my eyes to respond after the breathing tube is in my throat."
2. "I will be given frequent mouth care to help me when I am thirsty."
3. "I will be able to move about freely in bed and into the chair without help while connected to the
electronic equipment for monitoring."
4. "I may need something to help me rest due to the unfamiliar lights and sounds of the ICU unit."
5. "I might not behave like my usual self after the surgery but it will be because of the medications and
my illness." - Answer 1,2,4,5
When providing care to critically ill patients, whether they are responsive or unresponsive, the nurse
should:
,1. Clearly explain what care is to be done before starting the activity.
2. Perform the activity and then let the patient rest without explaining the care.
3. Make sure the patient always responds and is cooperative before giving care.
4. Explain to the family that the patient will not understand or remember any of the discomfort
associated with care. - Answer 1
Which communication strategy is most appropriate for a critical care nurse to use when communicating
with a ventilated patient? The nurse should:
1. Use professional terminology and provide the patient with detailed information.
2. Use simple language and explain in other terms if the patient does not seem to understand.
3. Provide minimal information so the patient is not overwhelmed.
4. Discuss issues primarily with the family because the patient is unlikely to understand the information.
- Answer 2
During an assessment, a ventilated patient begins to frown and wiggle about in bed. Which assessment
strategy would be most helpful for the nurse to validate these observations?
1. Glasgow Scale
2. Maslow's hierarchy levels
3. Critical-Care Pain Observation Tool (CPOT)
4. Vital signs trends - Answer 3
Which parameters indicate that a patient in the intensive care unit being mechanically ventilated is
ready for an interruption in sedation? The patient:
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Had a MAP of 75 and heart rate of 76
2. Was sleeping but awakened with verbal stimuli
3. Frowned when turned but otherwise showed no muscular tension
4. Activated the ventilator alarms but the alarms stopped spontaneously
5. Is receiving neuromuscular blocking agents to ensure adequate ventilation - Answer 1,2,3,4
, A patient scores positive on the Confusion Assessment Method of the Intensive Care Unit (CAM-ICU).
Which nursing diagnosis would have the highest priority based on this positive score?
1. Injury, Risk for
2. Family Processes, Altered
3. Social Interaction, Impaired
4. Memory Impaired - Answer 1
Which nursing actions would be appropriate when a nurse is initiating an infusion of morphine sulfate
for a post-operative patient who is experiencing pain?
1. Anticipate that the patient will begin to experience the effect of the morphine 15 minutes after the
start of the infusion.
2. Provide additional intermittent boluses of morphine sulfate if the patient experiences breakthrough
pain.
3. Complete the Critical-Care Pain Observation Tool scale 5 minutes after increasing the infusion rate
each time.
4. Begin the infusion at the lowest ordered dose and increase the rate every 30 minutes if the patient
continues to have pain. - Answer 2
Which strategies should the nurse include in the plan of care when trying to minimize sleep disruptions
for a patient in an ICU?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Instituting a short course of therapy for sleeping agents
2. Accurate scoring and vigilance in sedation and sedation scoring
3. Managing the environment to reduce lighting, sounds, and so on
4. Minimizing staff interruptions during sleep periods
5. Scheduling treatments only during the day or at least 4 hours apart at night - Answer 1,2,3,4
A nurse is confirming the medication orders and schedule for sedative administration to a patient with
delirium. Which schedule would maximize the effectiveness of the drugs? Administration of medication:
1. Only in the early morning
