Nursing Management: Critical Care Practice
Questions and Answers Verified by Expert
An acutely ill patient is receiving in the hospital's critical care unit. In addition to being delirious, the
patient is simultaneously exhibiting significant signs of anxiety. The critical care nurse should recognize
that this patient has a heightened risk of having what nursing diagnosis?
A) Risk for Aspiration
B) Risk for Impaired Skin Integrity
C) Risk for Injury
D) Risk for Imbalanced Body Temperature - Answer Correct response:
Risk for Injury
Explanation:
A delirious patient who is also experiencing anxiety is at risk of injuring himself or herself; interventions
to prevent this are necessary. Risks of aspiration or impaired skin integrity are not implausible, but these
are less likely than injury. Anxiety and delirium do not normally contribute to impaired temperature
regulation.
A patient is being treated in the critical care unit for urosepsis. The patient's level of consciousness has
decreased over the past 12 hours, but the nurse is continuing to conduct regularly scheduled pain
assessments in the knowledge that:
A) Pain is associated with a consequent decrease in renal function.
B) Pain blunts the patient's awareness of other important signs and symptoms.
C) Pain contributes to hyperglycemia and hypoglycemia.
D) Pain increases the patient's cardiac workload. - Answer Correct response:
Pain increases the patient's cardiac workload.
Explanation:
,It is well known that pain elicits a stress response leading to a catabolic state with increased cardiac
workload and an impaired immune response. Care must be taken to ensure that all ICU patients are
assessed for any pain whether or not they are able to communicate their pain.
A patient who has been admitted to the intensive care unit (ICU) with extensive burns is conscious but
unable to speak due to upper airway trauma. When communicating with this patient, the ICU nurse
should adopt which of the following strategies?
A) Provide brief explanations and directions to the patient.
B) Ask the patient questions that can be answered with a nod or a shake of the head.
C) Defer to a friend or family member of the patient when information is needed.
D) Speak to the patient slowly and with increased volume. - Answer Correct response:
Ask the patient questions that can be answered with a nod or a shake of the head.
Explanation:
Communication strategies for patients who cannot speak include asking yes or no questions to which
patients may nod their head. There is no indication that the patient has a deficit in cognition of
understanding, so speaking more slowly or loudly than normal is unnecessary. It would be inappropriate
to defer to the patient's friend or family member if the patient is conscious.
A 70-year-old woman was admitted to the medical unit with a diagnosis of pyelonephritis but failed to
respond appreciably to antibiotic therapy. Upon demonstrating warning signs and symptoms of septic
shock, the patient has transferred to the intensive care unit for treatment. Recent assessments suggest
that the patient's infection is now beginning to resolve. What types of monitoring and assessment are
likely to be required in this patient's immediate care? Select all that apply.
A) Peripheral intravenous access
B) Arterial line access
C) Pulmonary artery catheterization
D) Ventricular assist device
E) Cardiac monitoring - Answer A) Peripheral intravenous access
E) Cardiac monitoring
, Reason:
Fluid replacement must be instituted to correct the hypovolemia that results from the incompetent
vasculature and the inflammatory response.
Fluid resuscitation should be initiated early and aggressively in patients with shock to maximize
intravascular volume. For example, in patients with septic shock, an intravenous fluid challenge (20 to 30
mL/kg) may be given rapidly of crystalloid IV fluid to improve intravascular volume.
Initially, two large-bore peripheral IVs (at least 16 gauge) are inserted to prepare for fluid administration
Current treatment of septic shock involves identification and elimination of the cause of infection and
aggressive cardiopulmonary support to prevent or limit end-organ damage and death.
5. An arterial line has been ordered for a patient who is receiving treatment in the critical care unit. The
nurse on the unit should recognize that this patient will benefit from:
A) Bolus infusion of intravenous solution
B) Simultaneous administration of more than one antibiotic
C) Frequent blood pressure monitoring
D) Serial blood culture samples - Answer Correct response:
Frequent blood pressure monitoring
Explanation:
An arterial line is a peripheral IV in the arterial system used for frequent blood pressure monitoring
when a patient requires vasoactive medications (such as nitroprusside) and frequent blood sampling. It
is not for administration of fluids or medications and blood is not drawn from the line.
An acutely ill patient has had a pulmonary artery catheter (PAC) placed and the critical care nurse is
closely monitoring the data that the PAC provides. When documenting the patient's mean arterial
pressure, the nurse understands that this value represents:
A) The midpoint between the patient's systolic arterial blood pressure and diastolic arterial blood
pressure
B) The average arterial blood pressure throughout the patient's cardiac cycle
Questions and Answers Verified by Expert
An acutely ill patient is receiving in the hospital's critical care unit. In addition to being delirious, the
patient is simultaneously exhibiting significant signs of anxiety. The critical care nurse should recognize
that this patient has a heightened risk of having what nursing diagnosis?
A) Risk for Aspiration
B) Risk for Impaired Skin Integrity
C) Risk for Injury
D) Risk for Imbalanced Body Temperature - Answer Correct response:
Risk for Injury
Explanation:
A delirious patient who is also experiencing anxiety is at risk of injuring himself or herself; interventions
to prevent this are necessary. Risks of aspiration or impaired skin integrity are not implausible, but these
are less likely than injury. Anxiety and delirium do not normally contribute to impaired temperature
regulation.
A patient is being treated in the critical care unit for urosepsis. The patient's level of consciousness has
decreased over the past 12 hours, but the nurse is continuing to conduct regularly scheduled pain
assessments in the knowledge that:
A) Pain is associated with a consequent decrease in renal function.
B) Pain blunts the patient's awareness of other important signs and symptoms.
C) Pain contributes to hyperglycemia and hypoglycemia.
D) Pain increases the patient's cardiac workload. - Answer Correct response:
Pain increases the patient's cardiac workload.
Explanation:
,It is well known that pain elicits a stress response leading to a catabolic state with increased cardiac
workload and an impaired immune response. Care must be taken to ensure that all ICU patients are
assessed for any pain whether or not they are able to communicate their pain.
A patient who has been admitted to the intensive care unit (ICU) with extensive burns is conscious but
unable to speak due to upper airway trauma. When communicating with this patient, the ICU nurse
should adopt which of the following strategies?
A) Provide brief explanations and directions to the patient.
B) Ask the patient questions that can be answered with a nod or a shake of the head.
C) Defer to a friend or family member of the patient when information is needed.
D) Speak to the patient slowly and with increased volume. - Answer Correct response:
Ask the patient questions that can be answered with a nod or a shake of the head.
Explanation:
Communication strategies for patients who cannot speak include asking yes or no questions to which
patients may nod their head. There is no indication that the patient has a deficit in cognition of
understanding, so speaking more slowly or loudly than normal is unnecessary. It would be inappropriate
to defer to the patient's friend or family member if the patient is conscious.
A 70-year-old woman was admitted to the medical unit with a diagnosis of pyelonephritis but failed to
respond appreciably to antibiotic therapy. Upon demonstrating warning signs and symptoms of septic
shock, the patient has transferred to the intensive care unit for treatment. Recent assessments suggest
that the patient's infection is now beginning to resolve. What types of monitoring and assessment are
likely to be required in this patient's immediate care? Select all that apply.
A) Peripheral intravenous access
B) Arterial line access
C) Pulmonary artery catheterization
D) Ventricular assist device
E) Cardiac monitoring - Answer A) Peripheral intravenous access
E) Cardiac monitoring
, Reason:
Fluid replacement must be instituted to correct the hypovolemia that results from the incompetent
vasculature and the inflammatory response.
Fluid resuscitation should be initiated early and aggressively in patients with shock to maximize
intravascular volume. For example, in patients with septic shock, an intravenous fluid challenge (20 to 30
mL/kg) may be given rapidly of crystalloid IV fluid to improve intravascular volume.
Initially, two large-bore peripheral IVs (at least 16 gauge) are inserted to prepare for fluid administration
Current treatment of septic shock involves identification and elimination of the cause of infection and
aggressive cardiopulmonary support to prevent or limit end-organ damage and death.
5. An arterial line has been ordered for a patient who is receiving treatment in the critical care unit. The
nurse on the unit should recognize that this patient will benefit from:
A) Bolus infusion of intravenous solution
B) Simultaneous administration of more than one antibiotic
C) Frequent blood pressure monitoring
D) Serial blood culture samples - Answer Correct response:
Frequent blood pressure monitoring
Explanation:
An arterial line is a peripheral IV in the arterial system used for frequent blood pressure monitoring
when a patient requires vasoactive medications (such as nitroprusside) and frequent blood sampling. It
is not for administration of fluids or medications and blood is not drawn from the line.
An acutely ill patient has had a pulmonary artery catheter (PAC) placed and the critical care nurse is
closely monitoring the data that the PAC provides. When documenting the patient's mean arterial
pressure, the nurse understands that this value represents:
A) The midpoint between the patient's systolic arterial blood pressure and diastolic arterial blood
pressure
B) The average arterial blood pressure throughout the patient's cardiac cycle
