CRITICAL CARE NURSING 3 COMPREHENSIVE EXAM SCRIPT COMPLETE QUESTIONS
VERIFIED SOLUTIONS
Question:
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
Question:
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
Question:
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
,Question:
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
Question:
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
Question:
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
Question:
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
Question:
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:
Question:
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
Question:
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 2. Only at bedtime (HS) 3. Around the clock with higher
dosages in the evening 4. Only on an as-needed (PRN) basis.
Answer:
3
VERIFIED SOLUTIONS
Question:
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
Question:
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
Question:
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
,Question:
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
Question:
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
Question:
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
Question:
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
Question:
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:
Question:
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
Question:
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 2. Only at bedtime (HS) 3. Around the clock with higher
dosages in the evening 4. Only on an as-needed (PRN) basis.
Answer:
3
