546 Exam 1 Practice Questions with correct answers

Which of the following is NOT a likely sign of pain in a patient who cannot verbally communicate with you? a.Eyes clenched shut when turning the patient b.Decreased respiratory rate c.Patient resists bending of her elbow when you try to contract her arm d.Heart rate of 120 in a 54 year old male B. a decreased respiratory rate is not commonly associated with pain. This could actually be due to too much opioid analgesia depressing the patient's respiratory system You are assessing your intubated, post-operative patient and note the following findings: •Grimacing •Restlessness •Ventilator asynchrony • Tense muscles resistant to passive motion. What would you assess his pain as utilizing the Critical-Care Pain Observation Tool (CPOT)? A.5 B.6 C.7 D.8 C: score of 7 2 for facial expressions 2 for body movements 2 for ventilator compliance 1 for muscle tension You walk into your intubated patient's room with an IV fentanyl drip at 25mcg/hour who presents with the following: Heart rate: 130 BP: 140/90 RR: 29 Which of the following should the nurse do first? 1.Ask the patient to rank her pain on a scale of 0-10 2.Increase the fentanyl drip rate per protocol 3.Call the physician for additional pain medication orders 4.Get a music therapy consult 5.Look at the patient's facial expression and muscle tension Correct answer: 5 (assess first) You walk into your intubated patient's room with an IV fentanyl drip at 25mcg/hour who presents with the following: Heart rate: 130 BP: 140/90 RR: 29, ventilator alarming Hands clenched, brow narrowed, patient eyes open and looking at you anxiously. Which of the following should the nurse do first? 1.Ask the patient "Are you in pain?" 2.Stop the fentanyl drip and request orders for a new analgesic 3.Increase the fentanyl drip rate per protocol 4.Tell the patient to calm down 5.Get a music therapy consult 1- assess first Which of the following is true about sedating patients in the ICU? 1.Patients in the ICU must be sedated 2.Most patients who are intubated are sedated 3.All sedative medications provide pain relief 4.Sedated patients require less monitoring 2. Most patients who are intubated are sedate Not everyone is sedated in the ICU, this is done mostly for patient comfort, to facilitate interventions, reduce anxiety/fear/agitation and other reasons listed in the Awati article (required class reading). While some pain medications may be used for sedation, not all sedation provides pain relief (eg. Midazolam, propofol) Which of the following BEST describes delirium? 1.Long term memory loss 2.Anger 3.Chronic hallucinations 4.Inability to focus 4.Inability to focus Inattention is the number one sign of delirium- short term memory loss, restlessness, acute confusion are also notable- delirium is an acute problem, not chronic What is a nurse allowed to do once a patient is on a propofoldrip for sedation? 1.Administer boluses for acute agitation 2.Increase the drip rate 3.Change to Midazolam if it's ineffective 4.Make minor changes to the protocol 2. Increase the drip rate The nurse can increase the drip rate per protocol- boluses are not within our scope of practice. Changes cannot be made to the protocol and medication changes must be ordered by the physician Which of the following patients is MOST likely to be experiencing delirium? A. 94 year old female who answered "September 5" instead of "September 15" when asked what day it is B. 34 year old male diagnosed with a right femur fracture who is talking in his sleep after receiving 1mg of Dilaudid IV C. An 81 year old male who was alert and oriented x4 yesterday, but appears upset with you today . He is convinced you are the city police and that you are trying to take him back to jail. D. 79 year old female admitted with a GI bleed who you cared for yesterday that does not remember your name. She also thought it was 8pm instead of 8am before you brought in her breakfast tray C. An 81 year old male who was alert and oriented x4 yesterday, but appears upset with you today . He is convinced you are the city police and that you are trying to take him back to jail. Which of the following could be appropriate nursing interventions for the patient experiencing delirium? (Select all that apply) -Reorient the patient as needed -Monitor for potential risk factors such as dehydration, constipation, or pain -Ensure the patient always has an indwelling urinary catheter to reduce incontinence -Ensure the patient has any devices in place such as glasses or hearing aids -Wake the patient up frequently during the night to remind the patient of where he/she is -Provide the patient with puzzles, washcloths to fold, or a coloring book -Reorient the patient as needed -Monitor for potential risk factors such as dehydration, -constipation, or pain -Ensure the patient has any devices in place such as glasses or hearing aids -Provide the patient with puzzles, washcloths to fold, or a coloring book Which of the following is an appropriate assessment tool for delirium in the ICU? A. Ramsey Scale B. RAAS C. CPOT D. CAM-ICU D. CAM-ICU Which of the following is true about pharmacologic management of delirium? A. Most sedatives are not associated with delirium in ICU patients B. Benzodiazepines and narcotics may actually worsen a patient's cognition rather than treat delirium C. One of the risk factors of Haloperidol is a shortened QT interval D. Once a patient has been given a medication to treat delirium, further assessment is typically not necessary B. Benzodiazepines and narcotics may actually worsen a patient's cognition rather than treat delirium Which of the following is true about delirium? A. Delirium is often a choice, patients can choose whether or not they want to be delirious B. Delirium has an acute onset C. Patients with delirium can be given instructions with multiple steps and will have an intact short term memory D. Assessment of delirium should be completed one time: upon admission to the ICU B. Delirium has an acute onset Which of the following patients most likely needs to be sedated? A. A 24 year old male reporting 9/10 pain admitted after a motor vehicle accident with a fractured right humerus. B. A 45 year old female admitted status post gunshot wound to the abdomen. She has just undergone abdominal surgery and is coming to the ICU on a ventilator C. A 2 year old male admitted to the telemetry unit who is recovering from a right hip replacement surgery with no complications (post-op day 3) D. A 64 year old male admitted to the ICU with atrial fibrillation and a large deep vein thrombosis in his right femoral vein B. A 45 year old female admitted status post gunshot wound to the abdomen. She has just undergone abdominal surgery and is coming to the ICU on a ventilator Which of the following are appropriate for assessing pain in a nonverbal patient? (Select all that apply) -Assess facial expression -Assess Temperature -Assess changes in heart rate -Assess resistance to passive movement of the arms -Assess facial expression -Assess changes in heart rate -Assess resistance to passive movement of the arms Which of the following would be an appropriate intervention by the nurse to reduce pain for a nonverbal patient who is fidgeting in bed? A. Change medication order from tylenol to fentanyl drip B. Increase the fentanyl drip per protocol and have a family member help you play music from the patient's cell phone C. Increase the patient's propofol drip rate within the parameters listed on the protocol D. Decrease the patient's propofol drip rate within the parameters listed on the protocol B. Increase the fentanyl drip per protocol and have a family member help you play music from the patient's cell phone Which of the following is an appropriate scale to assess level of sedation in an ICU patient? A. Ramsay Sedation Scale B. ICUOPT Sedation Scale C. COPT Scale D. Wong Baker Sedation Scale A. Ramsay Sedation Scale