Feel free to use these questions elsewhere, but please credit me by linking back to this site. Answer key with rationales found below.
1) A patient’s family is anxious as the patient approaches end-of-life. Which nursing intervention best helps to support the family at this time?
- Explain what will happen to the patient as quickly as possible and then give the family time to process the information on their own
- Assure the family they should not assist in taking care of the patient as this will be taken care of only by the nursing staff
- Emphasize that the patient will not be abandoned
- Arrange for the family to meet with a chaplain regardless of their beliefs
2) An ICU nurse is aware of the quality and safety issues in critical care. Which actions by the nurse demonstrate knowledge of these issues and the measures taken to prevent them? (Select all that apply)
- Using the SBAR method of communication when requesting an order from the attending physician
- Using a urinary catheter whenever possible to accurately record I/O
- Turning and repositioning the patient every shift
- Participating in multidisciplinary bedside rounds
3) A nurse is concerned that a patient is developing delirium due to sensory overload. What measures by the nurse will help to reduce sensory overload in the critical care setting? (Select all that apply)
- Using bright lights so that the patient can see clearly
- Encouraging family and staff to keep conversations quiet or in another area of the hospital
- Combining nursing activities, interventions, and procedures
- Reorient that patient to day and time and explain the situation clearly and concisely
4) Which of the following are signs/symptoms of pain? (Select all that apply)
5) The nurse wants to do a pain assessment on a sedated patient with an endotracheal tube. The best way for the nurse to do this is
- Asking the patient to rate their pain on scale of 1-10
- Using the Behavioral Pain Scale
- Asking the patient’s spouse if she thinks he is in pain
- The nurse cannot assess pain in this patient
6) The critical care nurse notes that a patient has orders for both Fentanyl and Morphine. The nurse knows which of the following is correct regarding these opioid medications?
- Morphine has longer duration the Fentanyl
- Fentanyl has a fairly slow onset
- The nurse will need to assess the patient for tachypnea
- Narcan is contraindicated if a patient is on an opioid medication
7) A patient is experiencing hyperactive delirium. The nurse should anticipate which of the following medications to be ordered?
- Hydromorphone (Dilaudid)
- Dexmedetomidine (Precedex)
8) The nurse realizes which of the following is true with regards to caring for a patient on a mechanical ventilator?
- A patient on a neuromuscular blockade agent will not need a sedative administered
- It is important to keep the head of the bed raised at least 15 degrees
- The patient should be given a “Sedation vacation” every three days
- The nurse will titrate sedation per physician’s orders based on a scale such as the RASS
9) The nurse is caring for an elderly patient in the ICU. The nurse realizes the patient has increased risks related to which of the following? (Select all that apply)
- Cognitive impairments
- Tissue and organ changes
- Better vision and hearing lead to increased risk for sensory overload
10) A malnourished patient is admitted to the hospital. The nurse knows which of the following is an appropriate intervention?
- Immediately start the patient on TPN
- Monitor the patient’s albumin level
- Once enteral feedings are initiated, assess the patient’s bowel sounds regularly
- Hold feedings if the gastric residual is under 200mL
Rationale: Families are often concerned that when extraordinary measures are discontinued that patient’s care will be neglected in favor of other patients. Assuring the family that the patient will not be abandoned is an appropriate intervention. When giving the family information, assess their current understanding, be clear and concise with explanations, and allow the family time to express concerns and ask questions. Family should be encouraged to assist in the patient’s care as they are able, and spiritual counseling should take into account the culture and beliefs of the family.
2) 1, 4
Communication and collaboration are important to facilitating safe, effective patient care. Using SBAR and participating in multidisciplinary bedside rounds are two ways to facilitate effective and collaborative communication. Use of urinary catheters should be avoided when possible to decrease the chance of the patient contracting a UTI. The patient should be turned and repositioned Q2-4HR to prevent skin breakdown.
3) 2, 3, 4
Lights should be kept dim at night if possible to facilitate the sleep/wake cycle. Unnecessary noise, such as loud conversations, should be avoided. It is helpful to combine nursing activities, interventions, and procedures so that the patient has an opportunity to rest in between activities. Reorienting the patient helps to decrease anxiety about the environment.
4) 2, 3
Tachycardia, tachypnea, hypertension, increased gluconeogenesis, and urinary retention are all signs/symptoms of pain. Other signs/symptoms include increased cardiac output, pallor/flushing, cool extremities, diaphoresis, pupil dilation, nausea, constipation, and sleep disturbances.
Using a nonverbal pain scale tool is the best way to assess pain in a patient who cannot verbally communicate or point to a scale. Although the family can be helpful in interpreting the patient’s nonverbal indicators of pain, using an objective pain scale is the best way. Asking the patient to rate their pain on a scale of 1-10 would not be appropriate for a sedated patient with an endotracheal tube.
Morphine has a longer duration than Fentanyl. Fentanyl has a rapid onset. Opioid medications cause respiratory depression (bradypnea). Narcan should be on hand when administering these medications as it is a reversal agent for opioids.
Haldol is the drug of choice for delirium. Ibuprofen (an NSAID) and hydromorphone (an opioid) are appropriate for analgesia. Dexmedetomidine is used for sedation during initial intubation.
RASS (Richmond Agitation-Sedation Scale) is a commonly used assessment tool when sedating patients to ensure they are not over or under sedated. Patients on a NMB agent will also require a sedative, because NMB agents, which paralyze the patient, do not produce sedative effects. The head of the bed should be kept at 30-45 degrees to prevent Ventilator Associated Pneumonia (VAP). The patient should have a daily sedation vacation.
9) 1, 2, 4
The elderly have increased risks related to comorbidities, tissue and organ changes, cognitive impairments, and decline in sensory abilities.
Patient response to enteral feedings should be monitored, including assessment of bowel sounds. Patients should only be started on TPN if they are unable to tolerate enteral feedings or if enteral feedings cannot provide adequate nutrition for metabolic requirements. The nurse should monitor the patient’s pre-albumin level, as the pre-albumin level shows protein status in the last few days, while the albumin level shows the protein status over a longer span of time. Feedings should be held if the feeding is above 500mL (anything over 200-250mL is a concern).