AACN Essentials of Critical Care Nursing Exam Questions and Answers

AACN Essentials of Critical Care Nursing Exam Questions and Answers Immediate Assessment - Ans:-A - airway B - breathing C - circulation, cerebral perfusion, chief complaint D - drugs and diagnostic tests E - equipment Patient Safety Considerations - Ans:-Risk for pressure injury Delirium Infection Falls Airway - Ans:-Patency - Having the patient speak, watching the patient's chest rise and fall, or both Position of artificial airway (if present) ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 2/9 ET tubes - Ans:-Endotracheal tube Note the size and position of the airway Note the marking closest to the teeth, lips, or nares to assist with future comparisons for proper placement Suction the upper airway, either through the oral cavity or artificial airway to ensure that the airway is free from secretions Observe and document the amount, color, and consistency of any secretions removed Breathing - Ans:-Quantity and quality of respirations (rate, depth, pattern, symmetry, effort, use of accessory muscles) Breath sounds Presence of spontaneous breathing Observation of rate, depth, pattern, and symmetry of breathing The effort of breathing Use of accessory muscles Breathing synchrony with the ventilator ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 3/9 Circulation and Cerebral Perfusion - Ans:-ECG Rate, rhythm, and presence of ectopy Blood pressure Peripheral pulses and capillary refill Skin, color, temperature, moisture Presence of bleeding Level of consciousness, responsiveness Quickly palpating a pulse and viewing ECG Color, temperature, and moisture of the skin, capillary refill Chief Complaint - Ans:-Primary body system Associated symptoms Drugs and Diagnostic Tests - Ans:-Drugs prior to admission (prescribe