Ch 65 Critical Care

Which strategy helps to decrease the ICU client's risk of infection? 20sec Changing ECG electrodes daily Early exercise and mobility Frequent reorientation Handwashing

Handwashing

The intensive care unit (ICU) nurse is providing care for a patient who is at risk for developing delirium. Which environmental intervention could decrease this patient's risk for developing delirium? 1 Using opioid pain medication 2 Sedating the patient with benzodiazepines 3 Asking the family to sit with the patient at all times 4 Implementing a dark and quiet environment overnight

4 Implementing a dark and quiet environment overnight Environmental factors such as sleep deprivation can increase the patient's risk for developing delirium while being cared for in the intensive care unit (ICU) environment. Implementing a dark and quiet environment is one intervention that the nurse can use to decrease the patient's risk for delirium. Using opioid pain medication and benzodiazepines increase the patient's risk for delirium. Asking the family to sit at the patient's bedside at all times is not realistic and this will not decrease the patient's risk for developing delirium.

The intensive care unit (ICU) nurse is providing care to a patient who is improving after cardiovascular surgery. Which prescription does the nurse anticipate for this patient? 1 Transfer to the rehabilitative unit 2 Transfer to the long-term care unit 3 Transfer to the medical-surgical unit 4 Transfer to the progressive care unit

4 Transfer to the progressive care unit Progressive care units (PCUs), also called intermediate care or step-down units, provide a transition between the intensive care unit (ICU) and the general care unit or discharge. The nurse would not anticipate that the ICU patient would be transferred to the rehabilitative unit, long-term care unit, or the medical-surgical unit before being transferred to the PCU.

When caring for a client receiving enteral feedings, which action should the nurse take? 20sec Collaborate closely with the occupational therapist Keep the HOB < 30 to 45 degrees Verify placement by auscultating an air bolus prior to initiating feeding Implement feedings within 24-48 hours per doctor's orders

Implement feedings within 24-48 hours per doctor's orders

Prolonged bed rest can result in which of the following complications: Dementia Increased ventilator days Decreased hospital length of stay Hypertension

Increased ventilator days

Which action by the RN is recommended when a client is experiencing a crisis? 20sec Telling the client that everything will get better soon Listening to the client without expressing judgement Asking the client's spouse to explain the source of the client's crisis Explaining to the client that feelings of anger are not normal

Listening to the client without expressing judgement

What should the nurse assess prior to completing the CAM-ICU 20sec Vital signs Recent history of dysrhythmias Sedation level QT interval on the ECG

Sedation level

How should the nurse determine if a sedated client is in pain? 20sec Use a behavioral assessment scale Make this decision based on the client's vital signs Use the CAM-ICU assessment tool Ask the patient to rate their pain using the NRS

Use a behavioral assessment scale

Which is a significant risk factor for the development of delirium in the intensive care unit (ICU) patient? 1 Anxiety 2 Alcohol abuse 3 Type 2 diabetes mellitus 4 Impaired communication

2 Alcohol abuse is a significant risk factor for the development of delirium in a patient in the ICU. Type 2 diabetes mellitus does not contribute to the delirium. While they are not risk factors for delirium, anxiety and impaired communication should be addressed immediately to help the patient cope with his or her current situation.

Which environmental factors contribute to the development of delirium in the intensive care unit (ICU) patient? Select all that apply. 1 Hypoxemia 2 Immobilization 3 Benzodiazepines 4 Sleep deprivation 5 Sensory overload 6 Hemodynamic instability

2 Immobilization 4 Sleep deprivation 5 Sensory overload Environmental factors that contribute to delirium in the ICU patient include immobilization, sensory overload, and sleep deprivation. Hypoxemia and hemodynamic instability are examples of physical conditions, as opposed to environmental factors, that may cause delirium. Certain drugs including benzodiazepines may also contribute to the development delirium, but drugs are not considered environmental factors.

The nurse educator is teaching a group of students about the different ways in which patients in the intensive care unit (ICU) are clustered. Which example provided by the nurse educator exemplifies an ICU clustered by a disease process? 1 Labor and Delivery Unit 2 Pediatric Intensive Care Unit 3 Neonatal Intensive Care Unit 4 Cardiovascular Intensive Care Unit

4 Cardiovascular Intensive Care Unit The cardiovascular intensive care unit is an example of an intensive care unit that is clustered by disease process. The labor and delivery unit is a specialty unit, not an ICU. The pediatric intensive care unit and the neonatal intensive care unit are examples of an ICU that is clustered by the age of the patient that is receiving care, rather than disease process.

Which of the following actions help to support families of critically ill patients? 20sec Restricted visiting hours Education on equipment and patient appearance Limiting family presence during invasive procedures Ignoring the family's questions and concerns

Education on equipment and patient appearance

What factors contribute to sleep deprivation for patients admitted to the ICU? 20sec Fear and anxiety Clustering nursing tasks Calming music and lighting Proper alarm management

Fear and anxiety

Which is an alteration in mentation that can occur in a patient in the intensive care unit (ICU)? 1 Delirium 2 Lethargy 3 Restlessness 4 Nighttime agitation

1 Delirium is one of the alterations in mentation that can occur in the patient in the ICU. Lethargy and restlessness are examples of psychomotor status, and nighttime agitation is caused by an interruption in the sleep-wake cycle.

Which conditions involve acute and reversible sensory perceptual changes that can occur in patients in the intensive care unit (ICU)? Select all that apply. 1 Agitation 2 Lethargy 3 Delusions 4 Unresponsiveness 5 Short attention span 6 Prolonged periods of sleep

1 Agitation 2 Lethargy 3 Delusions 5 Short attention span Acute and reversible sensory perceptual changes that occur in ICU patients may include delusions, agitation, lethargy, and a short attention span. Unresponsiveness and prolonged periods of sleep are not characteristic of acute and reversible perceptual changes unless the patient is intentionally sedated.

The nurse is making room assignments for new admissions. Which patients should be placed in a room in the intensive care unit? Select all that apply. 1 An 82-year-old patient with respiratory failure 2 A 27-year-old patient with diabetic ketoacidosis 3 A 76-year-old male with congestive heart failure 4 A 15-year-old female with a urinary tract infection 5 A 58-year-old female who underwent a bowel resection

1 An 82-year-old patient with respiratory failure 2 A 27-year-old patient with diabetic ketoacidosis 3 A 76-year-old male with congestive heart failure Patients who have a high risk of life-threatening conditions should receive treatment in the intensive care unit (ICU). Therefore a patient with diabetic ketoacidosis, congestive heart failure, or respiratory failure should be admitted to the ICU for further medical management. A patient who underwent bowel resection without complications can be managed safely on the medical floor. A patient with a urinary tract infection can be safely managed on the medical floor.

The nurse is caring for a patient in the intensive care unit. When monitoring the patient, conditions may result in a hypermetabolic state? Select all that apply. 1 Burns 2 Sepsis 3 Acute liver disease 4 Acute kidney injury 5 Chronic heart disease

1 Burns 2 Sepsis Conditions such as burns and sepsis cause muscle wasting and lipid catabolism, resulting in a hypermetabolic state in the patient. Acute liver disease may result in malnourishment but not a hypermetabolic state. Acute kidney injury causes catabolic state. Chronic heart disease causes malnourishment.

Which are nonpharmacologic interventions that help reduce agitation and delirium in the intensive care unit (ICU) patient? Select all that apply. 1 Early mobility 2 Providing a clock 3 Turning off alarms 4 Caregiver presence 5 Providing a calendar 6 Immobilizing the patient

1 Early mobility 2 Providing a clock Caregiver presence 5 Providing a calendar Nonpharmacologic interventions that can reduce the risk of agitation and delirium in the ICU patient include introducing an early mobility protocol and allowing the presence of a caregiver to help orient the patient. Calendars and clocks help reorient the patient and decrease the occurrence of delirium. Turning off the alarms is an unsafe practice, and unnecessarily immobilizing the patient can contribute to delirium.

Which action by the nurse is most appropriate when bringing a family member of a critically ill patient into the intensive care unit (ICU) for the first time? 1 Give a description of what to expect 2 Ask the physician to accompany the family 3 Allow the family member to enter the room alone 4 Instruct the family not to touch and speak to the patient

1 Give a description of what to expect Prior to the family entering the intensive care unit (ICU) to visit a family member who is critically ill the nurse provides the family with a description of what to expect regarding the patient's appearance and the equipment that is being used to provide care to their family member. The nurse should accompany the family into the patient's room; it is not appropriate for the nurse to ask the physician to do this, nor is it appropriate for the family to enter the room alone. Although it is important to instruct the family on what to expect, the family should be encouraged to touch and speak to the patient.

A patient is admitted to the ICU. What care should a nurse take to ensure that the patient's sleep cycle is as normal as possible? Select all that apply. 1 Limit noise in the ICU. 2 Schedule regular rest periods. 3 Give regular sponge baths to the patient. 4 Encourage the caregiver to be with the patient at all times. 5 Dim the lights at night and open up the curtains during the day.

1 Limit noise in the ICU. 2 Schedule regular rest periods. 5 Dim the lights at night and open up the curtains during the day. Sleep disturbance is associated with delirium and delayed recovery. The ambience in the ICU should be properly arranged in order to promote the patient's sleep-wake cycle. Reducing the noise may facilitate sound sleep. Scheduling rest periods between activities may also enhance the ability to sleep. Strategies like dimming lights during the night and opening curtains during the day may also regulate the sleep-wake cycle. Regular sponging keeps the patient hygienic but doesn't directly affect the sleep pattern. Having a caregiver present keeps the patient calm and oriented, but doesn't affect the patient's sleep.

The nurse reviews medication profiles of several patients in the intensive care unit. Which classes of medication place the patient's at risk for the development of delirium? Select all that apply. 1 Opioids 2 Aminoglycosides 3 Benzodiazepines 4 Proton pump inhibitors 5 Histamine (H2)-receptor blockers

1 Opioids 2 Aminoglycosides 3 Benzodiazepines Opioids are central nervous system (CNS) depressants and may cause delirium in patients. Aminoglycosides are a class of antibiotics that may cause fluid electrolyte imbalance that may present as delirium. Benzodiazepines are anxiolytic medications that cause CNS depression and delirium in the patient. Proton pump inhibitors and histamine (H2)-receptor blockers are used to treat gastroesophageal reflux disease and peptic ulcer. They do not impair neurologic functioning and do not cause delirium.

A nurse is starting enteral feeding through a nasogastric tube for a patient in ICU. What advantages of enteral feeding over parenteral feeding does the nurse identify in the patient? Select all that apply. 1 Results in fewer complications 2 Can be administered to all patients 3 Prevents and corrects nutritional deficiencies 4 Preserves the structure and function of gut mucosa 5 Stops the movement of gut bacteria across the intestinal wall

1 Results in fewer complications 4 Preserves the structure and function of gut mucosa 5 Stops the movement of gut bacteria across the intestinal wall The primary goal of nutritional support is to prevent or correct nutritional deficiencies. This is usually done by the early provision of enteral nutrition or parenteral nutrition. Enteral nutrition preserves the structure and function of the gut mucosa and stops the movement of gut bacteria across the intestinal wall and into the bloodstream. In addition to this, early enteral nutrition is associated with fewer complications. Enteral feedings cannot be administered to all patients; in patients with paralytic ileus, intestinal obstruction, and GI ischemia, enteral feeding is contraindicated. In these patients, parenteral feeding is the best option.

The intensive care unit (ICU) nurse is providing care to a patient requiring intravenous (IV) polypharmacy. Which prescriptions is this patient receiving? Select all that apply. 1 Sedation 2 Thrombolytics 3 Vasopressor titration 4 Mechanical ventilation 5 Hemodynamic monitoring

1 Sedation 2 Thrombolytics 3 Vasopressor titration ICU patients often require intensive and complicated nursing support related to the use of IV polypharmacy and advanced technology. Prescriptions that are classified as IV polypharmacy include sedation, thrombolytics, and vasopressor titration. Mechanical ventilation and hemodynamic monitoring are advanced technology prescriptions.

The nurse wants to provide culturally competent care to patients requiring care in the intensive care unit (ICU). Which actions by the nurse are appropriate? Select all that apply. 1 Prioritizing cultural needs over physiologic needs 2 Asking the family about cultural traditions regarding death and dying 3 Asking the patient who he or she wants in the room at the time of death 4 Assuming that the patient follows cultural customs for the documented ethnicity 5 Telling the family members it is not possible for last rites to be administered

2 Asking the family about cultural traditions regarding death and dying 3 Asking the patient who he or she wants in the room at the time of death Providing culturally competent care to critically ill patients and caregivers is challenging. The nurse who wants to provide culturally competent care to critically ill patients in the intensive care unit (ICU) should ask the patient or family members who is wanted in the room at the time of death. The nurse should also ask the patient or family members about cultural traditions regarding death and dying. The nurse should not prioritize cultural needs over physiologic needs. Often physiologic needs are the priority in the ICU. The nurse should not assume that the patient follows cultural customs for the documented ethnicity. The nurse should not tell the family that last rites are not possible and should advocate for the patient to receive last rites if this is the patient's wish

The nurse is providing care to a patient in the intensive care unit (ICU) who is experiencing anxiety. Which nonpharmacologic relaxation intervention is appropriate for the nurse to provide for this patient? 1 Lorazepam 2 Music therapy 3 Sedation holiday 4 Range-of-motion exercises

2 Music therapy Music therapy is a nonpharmacologic relaxation intervention that can be used to treat the patient anxiety that often occurs in the intensive care unit (ICU) environment. Lorazepam is an appropriate pharmacologic, not nonpharmacologic, intervention for anxiety. A sedation holiday is appropriate to conduct a neurologic exam that is often difficult due to the deep sedation required for intubation and mechanical ventilation. Range-of-motion exercises can help treat the physical manifestations of an injury, but are not relaxation interventions.

The nurse is providing care to an adult patient in the intensive care unit (ICU). The patient's spouse is worried about a variety of things at home because the patient is the primary breadwinner in the family. Which consult will benefit this patient most based on this data? 1 Psychiatrist 2 Social worker 3 Physical therapist 4 Occupational therapist

2 Social worker Caregivers commonly experience anxiety over the financial issues related to the provision of care needed during a critical illness. Consulting with a case manager or a social worker is helpful in these instances. A psychiatrist may be needed if the family member is experiencing mental health issues as a result of the hospitalization. An occupational or physical therapist may be needed during the rehabilitative period of the patient's illness.

The nurse is providing care to a patient in the intensive care unit (ICU) who is of Hispanic descent. None of the patient's family members speak English. Which action by the nurse is most appropriate? 1 Talk to the family slowly and loudly 2 Ask a child from the family to act as a translator 3 Contact the hospital language line for a translator 4 Suggest that the family bring a translator when they visit

3 When communicating with patients and families that do not speak English the nurse should contact the hospital language line for a translator. Talking slowly and loudly is not appropriate. Asking a child from the family to act as a translator is not recommended due to the technical language that often needs to be interpreted. The nurse would not suggest that the family bring a translator with them when they visit due to the technical language and confidentiality issues that can arise.

The nurse is providing care to a patient in the intensive care unit (ICU). The patient is currently sedated due to intubation and mechanical ventilation. Which finding in the patient's medical record would place this patient at an increased risk for delirium? 1 Diabetes mellitus 2 Multiple sclerosis 3 Alzheimer's disease 4 Parkinson's disease

3 Alzheimer's disease Patients with preexisting dementia, such as Alzheimer's disease, are at an increased risk for developing delirium when receiving care in the intensive care unit (ICU). Diabetes mellitus, Parkinson's disease, and multiple sclerosis are not known risk factors for developing delirium.

The advance practice registered nurse (APRN) is seeking certification as an advance care nurse practitioner (ACNP). Which professional organization can grant this certification to the APRN? 1 National League of Nurses (NLN) 2 American Association of Nurse Practitioners (AANP) 3 American Association of Critical Care Nurses (AACN) 4 National Council of State Boards of Nursing (NCSBN

3 American Association of Critical Care Nurses (AACN) Certification as an advance care nurse practitioner (ACNP) is available through the American Association of Critical Care Nurses (AACN). The National League of Nurses (NLN), the American Association of Nurse Practitioners (AANP), and the National Council of State Boards of Nursing (NCSBN) are all nursing organizations but they do not offer certification to the advance practice registered nurse (APRN) as an ACNP.

A patient in the intensive care unit (ICU) is experiencing a loss of recent memory, restlessness, lethargy, and daytime sleepiness with nighttime agitation. What condition is this patient likely experiencing? 1 Pain 2 Anxiety 3 Delirium 4 ICU psychosis

3 Delirium A patient in the ICU who is experiencing symptoms of loss of recent memory, restlessness, lethargy, and daytime sleepiness with nighttime agitation is likely suffering from delirium. Pain and anxiety may occur in the patient in the ICU and should be immediately addressed, but the symptoms described do not relate to either of these. ICU psychosis is a form of delirium marked by a break with reality.

The patient has developed cardiogenic shock after a left anterior descending myocardial infection. Which circulatory assist device should the nurse expect to use for this patient? 1 Cardiopulmonary bypass 2 Impedance cardiography (ICG) 3 Intraaortic balloon pump (IABP) 4 Central venous pressure (CVP) measurement

3 Intraaortic balloon pump (IABP) The most commonly used mechanical circulatory assist device is the IABP, and it is used to decrease ventricular workload, increase myocardial perfusion, and augment circulation. Cardiopulmonary bypass provides circulation during open heart surgery. It is not used as an assist device after surgery. ICG is a noninvasive method to obtain cardiac output and assess thoracic fluid status. CVP measurement is an invasive measurement of right ventricular preload and reflects fluid volume problems.

A critical care nurse is assessing patients in the intensive care unit (ICU) for delirium. Which patient is most at risk for delirium? 1 The patient sitting at the edge of the bed during physical therapy 2 The patient who is conversing with a family member about the weather 3 The patient whose ventilator is continuously alarming during suctioning 4 The patient who has dexmedetomidine (Precedex) ordered for insomnia

3 The patient whose ventilator is continuously alarming during suctioning Environmental factors that contribute to delirium include sleep deprivation, anxiety, sensory overload, and immobilization. Limiting noise levels in the ICU, such as silencing ventilator alarms when suctioning, can help reduce sensory overload. The introduction of early mobility protocols has helped to reduce agitation and delirium in ICU patients. The use of dexmedetomidine (Precedex) produces anxiolytic effects for patients with insomnia. The presence of a caregiver or family member may help orient the patient and reduce agitation.

The nurse is providing care to a patient in the intensive care unit (ICU). Which intervention is most appropriate to keep the patient oriented? 1 Administer a sedative 2 Recommend a massage 3 Provide a clock in the room 4 Administer an opioid pain medicatio

3 Provide a clock in the room Providing a clock and a calendar in the patient's room is the best way to keep the patient oriented while in the intensive care unit (ICU) environment. A sedative will increase disorientation. A massage should be used for relaxation and to promote sleep. An opioid pain medication is likely to increase disorientation.

The nurse is caring for a patient in the intensive care unit (ICU) who is exhibiting hyperactivity, insomnia, and delirium. Which medication does the nurse prepare to administer? 1 Diazepam 2 Tobramycin 3 Oxycodone 4 Dexmedetomidine

4 Dexmedetomidine Dexmedetomidine is a sedative with an anxiolytic affect; it is used to treat patients experiencing hyperactivity, insomnia, and delirium in the ICU. Benzodiazepines (diazepam), aminoglycosides (tobramycin), and opioids (oxycodone) have been linked with the development of delirium in the ICU patient, so they would not be used to treat it.

The intensive care unit (ICU) charge nurse is reviewing patient medical records during the overnight shift. Which patient does the nurse anticipate will be transferred to the progressive care unit (PCU)? 1 The patient who required a new drip overnight for hypotension. 2 The patient who was intubated and ventilated after crashing overnight. 3 The patient who is 12 hours postop for a heart and lung transplantation. 4 The patient whose blood pressure is 100/70 mm Hg on a stable dose of a vasoactive drug.

4 The patient whose blood pressure is 100/70 mm Hg on a stable dose of a vasoactive drug Progressive care units (PCUs), also called intermediate care units, provide a transition between the intensive care unit (ICU) and the general care unit or discharge. Generally, PCU patients are at risk for serious complications, but their risk is lower than that of the ICU patient. Therefore the nurse anticipates that the patient with a stable blood pressure on a stable dose of a vasoactive drug will be transferred to the PCU. A patient who required a new drip overnight for hypotension and a patient who crashed and required intubation and mechanical ventilation are unstable and the nurse does not anticipate their transfer to the PCU. A preoperative heart transplant patient is often admitted to the PCU. A patient who is 12 hours post transplantation is not expected to be transferred to the PCU at this time.

The nurse is providing care for a patient in the intensive care unit (ICU) that is exhibiting symptoms of delirium. Which priority action should the nurse take when providing care to this patient? 1 Placing a clock in the room 2 Updating the calendar in the room 3 Administering opioid analgesics for pain 4 Administering increased oxygen, per order

4 Administering increased oxygen, per order When an intensive care unit (ICU) patient exhibits manifestations of delirium it is the nurse's priority to address physiologic factors that could be contributing to the patient's symptoms. Correction of oxygenation by increasing the patient's oxygen is the priority intervention for this patient. Placing a clock in the room and updating the calendar in the room are important when providing care to a patient with delirium but these are not the priorities in the current situation. Administering an opioid pain medication is likely to enhance the clinical manifestations of delirium.

Which type of critical care unit uses informatics to monitor a critically ill patient from a remote location? 1 Intensive care unit (ICU) 2 Coronary care unit (CCU) 3 Pediatric intensive care unit (PICU) 4 Electronic intensive care unit (teleICU)

4 Electronic intensive care unit (teleICU) The electronic or teleICU assists the bedside ICU team by monitoring the patient from a remote location using informatics. The ICU, CCU, and PICU are traditional critical care units.

The nurse is providing care to a patient who is admitted to the intensive care unit (ICU) with abdominal trauma. Which type of nutritional prescription does the nurse anticipate for this patient? 1 Oral feedings 2 Enteral feedings 3 Intravenous fluid 4 Parenteral nutrition

4 Parenteral nutrition Parenteral nutrition is used when the oral or enteral route cannot provide adequate nutrition or is contraindicated. Examples of these conditions are paralytic ileus, diffuse peritonitis, intestinal obstruction, pancreatitis, GI ischemia, abdominal trauma or surgery, and severe diarrhea. Intravenous nutrition will not provide enough calories or nutrients to meet this patient's nutritional needs.