What is a priority nursing intervention that is indicated for the patient in the ICU who
has a nursing diagnosis of anxiety r/t the ICU environment and sensory overload?
A. Provide flexible visiting schedules for caregivers
B. Eliminate unnecessary alarms and overhead paging
C. Administer sedatives or psychotropic drugs to promote rest
D. Allow the patient to do as many self-care activities as possible.
Give this one a try later!
, ANS: B
RATIONALE: Anxiety in the ICU patient may be r/t the environment, which
has unfamiliar equipment, high noise and light levels, and an intense pace
of activity that leads to sensory overload. The nurse should eliminate as
much of this source of stress as possible by muting phones, limiting
overhead paging, setting alarms appropriate to the patient's condition, and
eliminating unnecessary alarms during care when possible. A & D are
indicated when impaired communication and loss of control contribute to
anxiety. Use of sedation to reduce anxiety should be carefully evaluated
and implemented when nursing measures are not effective.
In preparing a patient in the ICU for oral ET intubation, what should the nurse do that
is MOST important for successful intubation?
A. Place the pt supine with the head extended and the next flexed
B. Tell the pt that the tongue must extruded while the tube is inserted
C. Position the pt supine with the head hanging over the edge of the bed to align the
mouth and trachea
D. Inform the pt that while it will not possible to talk during insertion of the tube,
speech will be possible after it is correctly placed.
Give this one a try later!
ANS: A
RATIONALE: Pt is positioned with head extended and the neck flexed in
the "sniffing position".
Before taking hemodynamic measurements, how must the nurse reference the
monitoring equipment?
A. Position the stopcock nearest the transducer level with the phlebostatic axis
B. Place the transducer on the left side of the chest at the fourth intercostal space
C. Confirm that when pressure in the system is zero, the equipment is functioning
D. Place the patient in a left lateral position with the transducer level with the top
surface of the mattress
,Give this one a try later!
ANS: A.
RATIONALE: Referencing hemodynamic monitoring equipment means
positioning the equipment so that the zero reference point is at the vertical
level of the left atrium of the heart. The stopcock nearest the transducer is
placed as the phlebostatic axis, the external landmark of the left atrium.
The client's ABG results are pH 7.34, PaCO2 50, HCO3 24, and PaO2 87. Which
intervention should the nurse implement first?
A. Have the client turn, cough, and deep breathe
B. Place the client on o2 via nasal cannula
C. Check the patient's pulse oximeter reading
D. Notify the HCP of the ABG results
Give this one a try later!
ANS: A
RATIONALE: These blood gases indicate respiratory acidosis that could be
caused by ineffective cough, with resulting air trapping. The nurse should
encourage the client to turn, cough, and deep breathe. PaO2 is within
normal limits. The ABG O2 value is an accurate test, the pulse ox is an
approximate level. The nurse can intervene to treat the client before
notifying the HCP.
The unlicensed assistive personnel (UAP) is
performing cardiac compressions on an adult
client during a code. Which behavior warrants
immediate intervention by the nurse?
1. The UAP has hand placement on the lower
half of the sternum.
2. The UAP performs cardiac compressions and
allows for rescue breathing.
3. The UAP depresses the sternum 0.5 to one
, (1) inch during compressions.
4. The UAP asks to be relieved from performing
compressions because of exhaustion.
Give this one a try later!
ANS: 3. The sternum should be depressed one
and one-half (1.5) to two (2) inches during
compressions to ensure adequate circulation
of blood to the body; therefore, the
nurse needs to correct the UAP.
RATIONALE:
1. This hand position will help prevent positioning
the hand over the xiphoid process,
which can break the ribs and lacerate the liver
during compressions.
2. This is the correct two-rescuer CPR;
therefore,
no intervention is needed.
4. The UAP should request another healthcare
provider to perform compressions when
exhausted.
TEST-TAKING HINT: The test taker must select
which option is an incorrect procedure for
cardiac compressions.
What nursing care is included for the patient with an ET tube?
A. Check the cuff pressure every hour
B. Keep a tracheostomy tray at the bedside
C. Hyperoxygenate before and after suctioning
D. Reuse the suction catheter at the bedside for 24 hours.
Give this one a try later!
has a nursing diagnosis of anxiety r/t the ICU environment and sensory overload?
A. Provide flexible visiting schedules for caregivers
B. Eliminate unnecessary alarms and overhead paging
C. Administer sedatives or psychotropic drugs to promote rest
D. Allow the patient to do as many self-care activities as possible.
Give this one a try later!
, ANS: B
RATIONALE: Anxiety in the ICU patient may be r/t the environment, which
has unfamiliar equipment, high noise and light levels, and an intense pace
of activity that leads to sensory overload. The nurse should eliminate as
much of this source of stress as possible by muting phones, limiting
overhead paging, setting alarms appropriate to the patient's condition, and
eliminating unnecessary alarms during care when possible. A & D are
indicated when impaired communication and loss of control contribute to
anxiety. Use of sedation to reduce anxiety should be carefully evaluated
and implemented when nursing measures are not effective.
In preparing a patient in the ICU for oral ET intubation, what should the nurse do that
is MOST important for successful intubation?
A. Place the pt supine with the head extended and the next flexed
B. Tell the pt that the tongue must extruded while the tube is inserted
C. Position the pt supine with the head hanging over the edge of the bed to align the
mouth and trachea
D. Inform the pt that while it will not possible to talk during insertion of the tube,
speech will be possible after it is correctly placed.
Give this one a try later!
ANS: A
RATIONALE: Pt is positioned with head extended and the neck flexed in
the "sniffing position".
Before taking hemodynamic measurements, how must the nurse reference the
monitoring equipment?
A. Position the stopcock nearest the transducer level with the phlebostatic axis
B. Place the transducer on the left side of the chest at the fourth intercostal space
C. Confirm that when pressure in the system is zero, the equipment is functioning
D. Place the patient in a left lateral position with the transducer level with the top
surface of the mattress
,Give this one a try later!
ANS: A.
RATIONALE: Referencing hemodynamic monitoring equipment means
positioning the equipment so that the zero reference point is at the vertical
level of the left atrium of the heart. The stopcock nearest the transducer is
placed as the phlebostatic axis, the external landmark of the left atrium.
The client's ABG results are pH 7.34, PaCO2 50, HCO3 24, and PaO2 87. Which
intervention should the nurse implement first?
A. Have the client turn, cough, and deep breathe
B. Place the client on o2 via nasal cannula
C. Check the patient's pulse oximeter reading
D. Notify the HCP of the ABG results
Give this one a try later!
ANS: A
RATIONALE: These blood gases indicate respiratory acidosis that could be
caused by ineffective cough, with resulting air trapping. The nurse should
encourage the client to turn, cough, and deep breathe. PaO2 is within
normal limits. The ABG O2 value is an accurate test, the pulse ox is an
approximate level. The nurse can intervene to treat the client before
notifying the HCP.
The unlicensed assistive personnel (UAP) is
performing cardiac compressions on an adult
client during a code. Which behavior warrants
immediate intervention by the nurse?
1. The UAP has hand placement on the lower
half of the sternum.
2. The UAP performs cardiac compressions and
allows for rescue breathing.
3. The UAP depresses the sternum 0.5 to one
, (1) inch during compressions.
4. The UAP asks to be relieved from performing
compressions because of exhaustion.
Give this one a try later!
ANS: 3. The sternum should be depressed one
and one-half (1.5) to two (2) inches during
compressions to ensure adequate circulation
of blood to the body; therefore, the
nurse needs to correct the UAP.
RATIONALE:
1. This hand position will help prevent positioning
the hand over the xiphoid process,
which can break the ribs and lacerate the liver
during compressions.
2. This is the correct two-rescuer CPR;
therefore,
no intervention is needed.
4. The UAP should request another healthcare
provider to perform compressions when
exhausted.
TEST-TAKING HINT: The test taker must select
which option is an incorrect procedure for
cardiac compressions.
What nursing care is included for the patient with an ET tube?
A. Check the cuff pressure every hour
B. Keep a tracheostomy tray at the bedside
C. Hyperoxygenate before and after suctioning
D. Reuse the suction catheter at the bedside for 24 hours.
Give this one a try later!
