NUR 445 Exam 1 UPDATED ACTUAL Questions and CORRECT Answers
Disordered sleep/wake cycles, invasive lines and monitoring, poor nutrition, anxiety,
What are risk factors for ICU delirium?
inability to wean off ventilator, oversedation
What assessment is used to assess for RASS - Richmond Agitation Sedation Scale
sedation with a mechanical vent?
How can the team determine patients' Richmond agitation sedation scale (RASS) with a goal of 0 or -1; the higher the score,
sedation level? the more combative; the lower the score, the more unarousable
What can occur due to prolonged use of Pressure ulcers, thromboembolic events, pneumonia, or delayed weaning from
sedatives? ventilators
What assessment is used to assess delirium CAM-ICU
with mechanical vent?
What is a CPAP? Provides continuous positive airway pressure during inhale and exhale
What is a BIPAP? Bilevel positive airway pressure, one during inhale, and another during exhale
Daily toothbrushing, perform daily spontaneous awakening trials, mouth care every 2
What are some ways to prevent ventilator-
hours, suctioning of the ETT routinely, care of the ventilator circuit, sterile water for
associated infections?
humidification
What are nursing interventions with invasive Keep patients' HOB elevated at 30 degrees, daily sedation vacations, GI prophylaxis,
O2 systems? DVT prophylaxis
What does it mean when there is a high Indicates mucus plugs or increased secretions, patient biting the ETT, pneumothorax,
pressure ventilator alarm going off? patient is anxious and fighting, or coughing in the ETT
What are interventions for this high- Suction as needed, insert oral airway to prevent biting, reevaluate the
pressure alarm? sedation/analgesia need
What does it mean if there is a low- Indicates cuff leak or leak in ventilator circuit
pressure alarm?
What are interventions for low-pressure Assess all connections and tubing, notify provider and RT
alarm?
, Ability to breathe spontaneously, ability to support oxygenation, ability to maintain
What is weaning criteria?
hemodynamic stability
Obstruction of the pulmonary arteries either with a blood clot, fat, air, or amniotic
What is a pulmonary embolism? fluid resulting in impaired ventilation-to-perfusion ratio (v/q mismatch)
*note: high-ventilation-perfusion mismatch
What are risk factors for PE? Virchow's triad for DVT (venous stasis, vessel wall damage, hypercoagulability)
What are signs and symptoms of a PE? Sudden dyspnea, pleuritic chest pain, tachypnea, tachycardia, crackles
EKG, chest x-ray, D-dimer (positive indicates presence of clot), angiography,
How can you diagnose PE?
troponin, ABG
Anticoagulants (heparin), antidote: protamine sulfate, oxygen, embolectomy when
How can you treat PE?
thrombolytics are contraindicated with systemic hypotension
What are nursing cautions when giving Monitor for HIT → platelets clump together due to reaction of heparin causing
heparin? decreased platelets and risk for bleeding
Elevate HOB, IV fluids, administer meds (anticoagulants or thrombolytics), bleeding
What are nursing actions for a PE?
precautions, prepare for intubation and resuscitation
Soft-bristle toothbrush, electric razor, stool softeners, no blowing nose, make sure
What are important bleeding precautions?
blade is sharp, avoid intramuscular injections
What are important teaching points for Lifestyle modifications like aerobic exercises, medication compliance, bleeding
bleeding precautions? precautions, limit food high in vitamin K, monitor for signs of recurrent PE/DVT.
When one or both gas exchange functions are compromised causing hypoxemia or
What is acute respiratory failure?
hypercapnia
What is hypoxemic (decreased O2) Decreased circulation of oxygen leading to hypoxia, caused by 3 P's: pneumonia,
respiratory failure? pulmonary edema, or pulmonary embolism.
What are signs and symptoms of RR, HR, and BP increase and late-stage cyanosis, restlessness, coma
hypoxemia?
What is hypercapnic (increased CO2) Reduced ability of lungs and respiratory apparatus to expand adequately, which
respiratory failure? impaired ventilation or causes hypoventilation
What are causes of hypercapnic respiratory Chest wall injury (trauma), asthma, narcotic OD, myasthenia gravis
failure?
What are signs and symptoms of Headache, confusion, decreased LOC, somnolence
hypercapnia?
Supplemental O2, Positive pressure ventilation, Medications, Bronchodilators +
What is the treatment for ARF?
Steroids, Diuretics, Sedations, ABX
What are complications of ARF? Cardiac failure, Respiratory arrest, Multi organ system dysfunction
Humidified oxygen, Elevate HOB, Position patient → 'good lung down', Chest
What are nursing interventions for ARF?
physiotherapy and suctioning, Fluids and hydration, Intubation
What are indications that a pt will need to PE - pulmonary embolism, ARDS - Acute Respiratory Distress Syndrome, Chest
be intubated? trauma
What is a condition that can arise with Ventilator associated infections
intubation?
What are nursing interventions to help with Monitor intubation attempts (15-30 sec), Gather intubation tray and CO2 detector,
intubation? Have restraints available if necessary, Ensure suction is available
Acute onset, refractory hypoxemia, and bilateral infiltrates consistent with pulmonary
What are characteristics of ARDS?
edema
What are the 3 phases of ARDS? Exudative phase, Proliferative phase, Fibrotic phase
Disordered sleep/wake cycles, invasive lines and monitoring, poor nutrition, anxiety,
What are risk factors for ICU delirium?
inability to wean off ventilator, oversedation
What assessment is used to assess for RASS - Richmond Agitation Sedation Scale
sedation with a mechanical vent?
How can the team determine patients' Richmond agitation sedation scale (RASS) with a goal of 0 or -1; the higher the score,
sedation level? the more combative; the lower the score, the more unarousable
What can occur due to prolonged use of Pressure ulcers, thromboembolic events, pneumonia, or delayed weaning from
sedatives? ventilators
What assessment is used to assess delirium CAM-ICU
with mechanical vent?
What is a CPAP? Provides continuous positive airway pressure during inhale and exhale
What is a BIPAP? Bilevel positive airway pressure, one during inhale, and another during exhale
Daily toothbrushing, perform daily spontaneous awakening trials, mouth care every 2
What are some ways to prevent ventilator-
hours, suctioning of the ETT routinely, care of the ventilator circuit, sterile water for
associated infections?
humidification
What are nursing interventions with invasive Keep patients' HOB elevated at 30 degrees, daily sedation vacations, GI prophylaxis,
O2 systems? DVT prophylaxis
What does it mean when there is a high Indicates mucus plugs or increased secretions, patient biting the ETT, pneumothorax,
pressure ventilator alarm going off? patient is anxious and fighting, or coughing in the ETT
What are interventions for this high- Suction as needed, insert oral airway to prevent biting, reevaluate the
pressure alarm? sedation/analgesia need
What does it mean if there is a low- Indicates cuff leak or leak in ventilator circuit
pressure alarm?
What are interventions for low-pressure Assess all connections and tubing, notify provider and RT
alarm?
, Ability to breathe spontaneously, ability to support oxygenation, ability to maintain
What is weaning criteria?
hemodynamic stability
Obstruction of the pulmonary arteries either with a blood clot, fat, air, or amniotic
What is a pulmonary embolism? fluid resulting in impaired ventilation-to-perfusion ratio (v/q mismatch)
*note: high-ventilation-perfusion mismatch
What are risk factors for PE? Virchow's triad for DVT (venous stasis, vessel wall damage, hypercoagulability)
What are signs and symptoms of a PE? Sudden dyspnea, pleuritic chest pain, tachypnea, tachycardia, crackles
EKG, chest x-ray, D-dimer (positive indicates presence of clot), angiography,
How can you diagnose PE?
troponin, ABG
Anticoagulants (heparin), antidote: protamine sulfate, oxygen, embolectomy when
How can you treat PE?
thrombolytics are contraindicated with systemic hypotension
What are nursing cautions when giving Monitor for HIT → platelets clump together due to reaction of heparin causing
heparin? decreased platelets and risk for bleeding
Elevate HOB, IV fluids, administer meds (anticoagulants or thrombolytics), bleeding
What are nursing actions for a PE?
precautions, prepare for intubation and resuscitation
Soft-bristle toothbrush, electric razor, stool softeners, no blowing nose, make sure
What are important bleeding precautions?
blade is sharp, avoid intramuscular injections
What are important teaching points for Lifestyle modifications like aerobic exercises, medication compliance, bleeding
bleeding precautions? precautions, limit food high in vitamin K, monitor for signs of recurrent PE/DVT.
When one or both gas exchange functions are compromised causing hypoxemia or
What is acute respiratory failure?
hypercapnia
What is hypoxemic (decreased O2) Decreased circulation of oxygen leading to hypoxia, caused by 3 P's: pneumonia,
respiratory failure? pulmonary edema, or pulmonary embolism.
What are signs and symptoms of RR, HR, and BP increase and late-stage cyanosis, restlessness, coma
hypoxemia?
What is hypercapnic (increased CO2) Reduced ability of lungs and respiratory apparatus to expand adequately, which
respiratory failure? impaired ventilation or causes hypoventilation
What are causes of hypercapnic respiratory Chest wall injury (trauma), asthma, narcotic OD, myasthenia gravis
failure?
What are signs and symptoms of Headache, confusion, decreased LOC, somnolence
hypercapnia?
Supplemental O2, Positive pressure ventilation, Medications, Bronchodilators +
What is the treatment for ARF?
Steroids, Diuretics, Sedations, ABX
What are complications of ARF? Cardiac failure, Respiratory arrest, Multi organ system dysfunction
Humidified oxygen, Elevate HOB, Position patient → 'good lung down', Chest
What are nursing interventions for ARF?
physiotherapy and suctioning, Fluids and hydration, Intubation
What are indications that a pt will need to PE - pulmonary embolism, ARDS - Acute Respiratory Distress Syndrome, Chest
be intubated? trauma
What is a condition that can arise with Ventilator associated infections
intubation?
What are nursing interventions to help with Monitor intubation attempts (15-30 sec), Gather intubation tray and CO2 detector,
intubation? Have restraints available if necessary, Ensure suction is available
Acute onset, refractory hypoxemia, and bilateral infiltrates consistent with pulmonary
What are characteristics of ARDS?
edema
What are the 3 phases of ARDS? Exudative phase, Proliferative phase, Fibrotic phase
