Exam 1 critical care
1. When planning care for a client who is critically ill, what action should the nurse implement to
decrease the client's stress?
a. Strictly limit visitors.
b. Play soft soothing music.
c. Set lighting for day/night cycles.
*d .Plan care to minimize interactions with the client.
2. The nurse is caring for a client with terminal cancer. It is essential for the
nurse to consider which aspect of this client's care?
a. Requesting that the chaplain visit the client.
*b. Compliance with the client's living will.
c. Maintaining a soothing environment.
d. Frequent family visitation.
3. When caring for an older adult client in the critical care setting, how can the nurse best assess for
pain?
a. Use the FACES Pain Scale.
*b. Observe non-verbal cues.
c. Use the visual analog scale.
d. Ask the client for a pain score.
4. What finding would the nurse address first following the administration of an opioid analgesic
in a client who is critically ill?..AKA..
……NOTES: THIS WAS SELECT ALL THAT APPLY: Correct answers are: Constipation,
Purities, Respiratory depress, Urinary retention
a. Hypotension
b. Constipation
c. Increased pain
*d. Respiratory depression
TYPE: MA
5. In caring for a terminally ill client during the ventilator weaning process, the nurse should be alert for
which signs of discomfort? (Select all that apply)
*a. Dyspnea
*b. Tachycardia
c. Bradycardia
d. Hypotension
*e. Use of accessory muscles
6. When caring for a client in the critical care setting, which environmental factor should the
nurse control to reduce stress?
*a. Noise
b. Light
c. Visitation
d. Lack of privacy
7. An intensive care nurse is receiving bedside report from members of the healthcare team for
further management of care. What information would require immediate action by the oncoming
team?
, a. Wheezes are noted throughout lung fields on auscultation.
*b. There is noted paradoxical thoracoabdominal movement.
c. Client is on a ventilator that includes the use of heliox.
d. Client has a prolonged exhalation.
8. A client reporting dyspnea and chest pain with inhalation is being prepared for a high-
resolution multidetector computed tomography angiography (MCDTA). What information would
the nurse include in the plan of care?
*a. The client should remain still during the diagnostic test
b. This is a nonspecific test, which could be positive with infections also
c. The client will have to have their legs available for the diagnostic test
d. This is an invasive test; afterwards the client will have to lie still for 4 hour
9. What does the nurse understand has the most potential to be a risk factor for acute respiratory
distress syndrome in a client undergoing general anesthesia for surgery?
a. Poor nutritional stasis
*b. Aspiration of gastric contents
c. Pregnancy
d. Chronic bronchitis
10. A client is receiving corticosteroids for the development of acute respiratory distress
syndrome (ARDS). What would the nurse evaluate to determine the client is not developing side
effects?
a. Monitor for lower extremity edema
b. Check skin turgor
*c. Assess the client’s mouth for thrush
d. Watch sclera for yellowing
11. A nurse is evaluating a post-operative client with chronic obstructive pulmonary disease for
surgical complications. What assessment finding would the nurse understand as a potential risk
factor for the development of post-surgical acute respiratory distress syndrome to be for this
client?
*a. client is not orientated to person, place, or situation
b. client’s last food prior to surgery was ten hours ago
c. client states “sitting upright helps my breathing”
d. Clubbing of the fingers
12. The nurse is caring for a client with acute respiratory distress syndrome (ARDS) and is on
mechanical ventilation. What is the primary reason the client is being mechanically ventilated?
a. So the client is fed via nasogastric tube.
b. So the client can be sedated and rest.
c. To maintain adequate blood pressure.
*d. To manage the client’s respirations.
13. . A client with acute respiratory distress syndrome (ARDS) on mechanical ventilation is
becoming increasingly restless. The client’s heart rate is 128 beats/min and oxygen saturation is
88% on FiO2 of 50%. Coarse rhonchi are audible in all lung fields on auscultation. What action
should the nurse implement?
1. When planning care for a client who is critically ill, what action should the nurse implement to
decrease the client's stress?
a. Strictly limit visitors.
b. Play soft soothing music.
c. Set lighting for day/night cycles.
*d .Plan care to minimize interactions with the client.
2. The nurse is caring for a client with terminal cancer. It is essential for the
nurse to consider which aspect of this client's care?
a. Requesting that the chaplain visit the client.
*b. Compliance with the client's living will.
c. Maintaining a soothing environment.
d. Frequent family visitation.
3. When caring for an older adult client in the critical care setting, how can the nurse best assess for
pain?
a. Use the FACES Pain Scale.
*b. Observe non-verbal cues.
c. Use the visual analog scale.
d. Ask the client for a pain score.
4. What finding would the nurse address first following the administration of an opioid analgesic
in a client who is critically ill?..AKA..
……NOTES: THIS WAS SELECT ALL THAT APPLY: Correct answers are: Constipation,
Purities, Respiratory depress, Urinary retention
a. Hypotension
b. Constipation
c. Increased pain
*d. Respiratory depression
TYPE: MA
5. In caring for a terminally ill client during the ventilator weaning process, the nurse should be alert for
which signs of discomfort? (Select all that apply)
*a. Dyspnea
*b. Tachycardia
c. Bradycardia
d. Hypotension
*e. Use of accessory muscles
6. When caring for a client in the critical care setting, which environmental factor should the
nurse control to reduce stress?
*a. Noise
b. Light
c. Visitation
d. Lack of privacy
7. An intensive care nurse is receiving bedside report from members of the healthcare team for
further management of care. What information would require immediate action by the oncoming
team?
, a. Wheezes are noted throughout lung fields on auscultation.
*b. There is noted paradoxical thoracoabdominal movement.
c. Client is on a ventilator that includes the use of heliox.
d. Client has a prolonged exhalation.
8. A client reporting dyspnea and chest pain with inhalation is being prepared for a high-
resolution multidetector computed tomography angiography (MCDTA). What information would
the nurse include in the plan of care?
*a. The client should remain still during the diagnostic test
b. This is a nonspecific test, which could be positive with infections also
c. The client will have to have their legs available for the diagnostic test
d. This is an invasive test; afterwards the client will have to lie still for 4 hour
9. What does the nurse understand has the most potential to be a risk factor for acute respiratory
distress syndrome in a client undergoing general anesthesia for surgery?
a. Poor nutritional stasis
*b. Aspiration of gastric contents
c. Pregnancy
d. Chronic bronchitis
10. A client is receiving corticosteroids for the development of acute respiratory distress
syndrome (ARDS). What would the nurse evaluate to determine the client is not developing side
effects?
a. Monitor for lower extremity edema
b. Check skin turgor
*c. Assess the client’s mouth for thrush
d. Watch sclera for yellowing
11. A nurse is evaluating a post-operative client with chronic obstructive pulmonary disease for
surgical complications. What assessment finding would the nurse understand as a potential risk
factor for the development of post-surgical acute respiratory distress syndrome to be for this
client?
*a. client is not orientated to person, place, or situation
b. client’s last food prior to surgery was ten hours ago
c. client states “sitting upright helps my breathing”
d. Clubbing of the fingers
12. The nurse is caring for a client with acute respiratory distress syndrome (ARDS) and is on
mechanical ventilation. What is the primary reason the client is being mechanically ventilated?
a. So the client is fed via nasogastric tube.
b. So the client can be sedated and rest.
c. To maintain adequate blood pressure.
*d. To manage the client’s respirations.
13. . A client with acute respiratory distress syndrome (ARDS) on mechanical ventilation is
becoming increasingly restless. The client’s heart rate is 128 beats/min and oxygen saturation is
88% on FiO2 of 50%. Coarse rhonchi are audible in all lung fields on auscultation. What action
should the nurse implement?
