NUR 425 Exam 1 - Critical Care UPDATED
ACTUAL Exam Questions and CORRECT
Answers
If a patient is delirious and hitting you and pulling out their wires, do you give them more
sedatives even though sedatives make delirium worse? - CORRECT ANSWER - Yes,
because they are a danger to themselves and others. If they were delirious but pleasant you
would try to avoid the sedatives.
Which of the following is NOT a likely sign of pain in a nonverbal patient?
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 - CORRECT ANSWER - b. Decreased
respiratory rate
If a patient is already on phentenyol but have a CPOT of 7 and are grimacing, what do you want
to do before you give them more pain meds? - CORRECT ANSWER - assess everything
first! are they laying on something?
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?
a. Ask the patient to rank her pain on a scale of 0-10
b. Increase the fentanyl drip rate per protocol
c. Call the physician for additional pain medication orders
,d. Get a music therapy consult
e. Look at the patient's facial expression and muscle tension - CORRECT ANSWER - e.
Look at the patient's facial expression and 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, ventilator alarming
Hands clenched, brow narrowed, patient eyes open and looking at you anxiously.
Which of the following should the nurse do first?
a. Ask the patient "Are you in pain?"
b. Stop the fentanyl drip and request orders for a new analgesic
c. Increase the fentanyl drip rate per protocol
d. Tell the patient to calm down
e. Get a music therapy consult - CORRECT ANSWER - a. Ask the patient "Are you in
pain?"
Midazolam - CORRECT ANSWER - Benzo of choice. Anterograde amnesia. Stored in the
body and can accumulate over time and cause prolonged sedation. Respiratory depression, but
not worried if on ventilator. Potential for tolerance and withdrawal.
Propofol - CORRECT ANSWER - white lipid drug. Look out for hyperlipidemia. Rapid
onset and rapid offset! Need to intubate the patient and be ready for breathing problems.
Hypotension. Nurse cannot push unless under doctor supervision.
Fentenyl - CORRECT ANSWER - Analgesia with rapid onset and offset. Respiratory
depression. Used with sedatives.
, Ativan - CORRECT ANSWER - sedative that decreases REM sleep
CAM-ICU scale - CORRECT ANSWER - assessment scale for delirium
RASS - CORRECT ANSWER - sedation scale
CPOT - CORRECT ANSWER - critical care pain observation tool
BPS - CORRECT ANSWER - Behavior pain scale
Which of the following patients is MOST likely to be experiencing delirium?
a. A 94 year old female who answered "September 5" instead of "September 15" when asked
what day it is
b. A 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. A 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. - CORRECT ANSWER - 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)
1. Frequently orient the patient
2. Monitor for potential risk factors such as dehydration, constipation, or pain
3. Ensure the patient always has an indwelling urinary catheter to reduce incontinence
4. Ensure the patient has any devices in place such as glasses or hearing aids
5. Wake the patient up frequently during the night to remind the patient of where he/she is
ACTUAL Exam Questions and CORRECT
Answers
If a patient is delirious and hitting you and pulling out their wires, do you give them more
sedatives even though sedatives make delirium worse? - CORRECT ANSWER - Yes,
because they are a danger to themselves and others. If they were delirious but pleasant you
would try to avoid the sedatives.
Which of the following is NOT a likely sign of pain in a nonverbal patient?
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 - CORRECT ANSWER - b. Decreased
respiratory rate
If a patient is already on phentenyol but have a CPOT of 7 and are grimacing, what do you want
to do before you give them more pain meds? - CORRECT ANSWER - assess everything
first! are they laying on something?
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?
a. Ask the patient to rank her pain on a scale of 0-10
b. Increase the fentanyl drip rate per protocol
c. Call the physician for additional pain medication orders
,d. Get a music therapy consult
e. Look at the patient's facial expression and muscle tension - CORRECT ANSWER - e.
Look at the patient's facial expression and 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, ventilator alarming
Hands clenched, brow narrowed, patient eyes open and looking at you anxiously.
Which of the following should the nurse do first?
a. Ask the patient "Are you in pain?"
b. Stop the fentanyl drip and request orders for a new analgesic
c. Increase the fentanyl drip rate per protocol
d. Tell the patient to calm down
e. Get a music therapy consult - CORRECT ANSWER - a. Ask the patient "Are you in
pain?"
Midazolam - CORRECT ANSWER - Benzo of choice. Anterograde amnesia. Stored in the
body and can accumulate over time and cause prolonged sedation. Respiratory depression, but
not worried if on ventilator. Potential for tolerance and withdrawal.
Propofol - CORRECT ANSWER - white lipid drug. Look out for hyperlipidemia. Rapid
onset and rapid offset! Need to intubate the patient and be ready for breathing problems.
Hypotension. Nurse cannot push unless under doctor supervision.
Fentenyl - CORRECT ANSWER - Analgesia with rapid onset and offset. Respiratory
depression. Used with sedatives.
, Ativan - CORRECT ANSWER - sedative that decreases REM sleep
CAM-ICU scale - CORRECT ANSWER - assessment scale for delirium
RASS - CORRECT ANSWER - sedation scale
CPOT - CORRECT ANSWER - critical care pain observation tool
BPS - CORRECT ANSWER - Behavior pain scale
Which of the following patients is MOST likely to be experiencing delirium?
a. A 94 year old female who answered "September 5" instead of "September 15" when asked
what day it is
b. A 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. A 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. - CORRECT ANSWER - 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)
1. Frequently orient the patient
2. Monitor for potential risk factors such as dehydration, constipation, or pain
3. Ensure the patient always has an indwelling urinary catheter to reduce incontinence
4. Ensure the patient has any devices in place such as glasses or hearing aids
5. Wake the patient up frequently during the night to remind the patient of where he/she is
