Essentials of Critical Care Nursing Chapter 1 & 2
1. 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: 2
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: 4
3. 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.":
4. 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.
, Essentials of Critical Care Nursing Chapter 1 & 2
4. Explain to the family that the patient will not understand or remember
any of the discomfort associated with care.: 1
5. 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.: 2
6. 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: 3
7. 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: 1,2,3,4
8. 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
, Essentials of Critical Care Nursing Chapter 1 & 2
3. Social Interaction, Impaired
4. Memory Impaired: 1
9. 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.: 2
10. 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: 1,2,3,4
11. 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: 3
12. Which patients would be at risk for nutritional imbalances? The patient:
Note: Credit will be given only if all correct choices and no incorrect choices
are selected.
1. 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: 2
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: 4
3. 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.":
4. 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.
, Essentials of Critical Care Nursing Chapter 1 & 2
4. Explain to the family that the patient will not understand or remember
any of the discomfort associated with care.: 1
5. 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.: 2
6. 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: 3
7. 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: 1,2,3,4
8. 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
, Essentials of Critical Care Nursing Chapter 1 & 2
3. Social Interaction, Impaired
4. Memory Impaired: 1
9. 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.: 2
10. 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: 1,2,3,4
11. 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: 3
12. Which patients would be at risk for nutritional imbalances? The patient:
Note: Credit will be given only if all correct choices and no incorrect choices
are selected.
