Module 1 - Intro to the ICU

Nursing strategies to help families cope with the stress of critical illness include: (Select all that apply.) A. if possible, providing continuity of nursing care. B. encouraging family members to make notes of questions they have for the physician during family rounds. C. providing a daily update of the patient's condition to the family spokesperson. D. allow family to bring their pet to help relieve stress.

A. if possible, providing continuity of nursing care. B. encouraging family members to make notes of questions they have for the physician during family rounds. C. providing a daily update of the patient's condition to the family spokesperson. Encouraging families to formulate questions assists in family care. Continuity of nursing care with consistent staff members assists in reducing stress. Communication of patient condition update meets the need for information.

A middle-aged client tells the nurse, "My mother died 4 months ago, and I just can't get over it. I'm not sure it is normal to still think about her every day." Which nursing diagnosis is most appropriate?

Anxiety related to lack of knowledge about normal grieving

The nurse is explaining to a client's spouse why an arterial line is needed to monitor the blood pressure for the hemodynamically unstable client. The nurse determines that the client's spouse understands the information when the spouse makes which statement? Select all that apply

Arterial lines provide continuous beat-to-beat monitoring of arterial pressure. Arterial lines provide real-time blood pressure monitoring

Which term describes the forcible ejection of blood from the left ventricle into the aorta and out into the arterial system?

Arterial pressure

As the nurse admits a patient in end-stage renal disease to the hospital, the patient tells the nurse, "If my heart or breathing stop, I do not want to be resuscitated." Which action should the nurse take first?

Ask if the decision has been discussed with the patient's health care provider.

The nurse assesses that a patient receiving epidural morphine has not voided for more than 10 hours. What action should the nurse take initially?

Ask if the patient feels the need to void.

The intensive care nurse is caring for a client who is receiving morphine through patient-controlled analgesia (PCA) for moderate pain and IV benzodiazepines for anxiety related to the unit environment. What action by the nurse is a priority?

Assess the respiratory rate.

The nurse is caring for a client undergoing arterial-pressure based cardiac output (APCO) monitoring. How often should the nurse zero the hemodynamic system and perform a square wave test?

At least every 12 hours

Which action will the nurse need to do when preparing to assist with the insertion of a pulmonary artery catheter?

Attach cardiac monitoring leads before the procedure.

The client's radial arterial catheter was removed 30 minutes ago. Upon assessing the site, the nurse finds that blood has seeped through the pressure dressing. Which situation is the most likely cause of the blood seepage?

Inadequate pressure dressing application

A client who is receiving sustained-release morphine sulfate every 12 hours for severe pain experiences level 9 (0 to 10 scale) breakthrough pain and anxiety. Which action by the nurse is appropriate for treating this change in assessment?

Offer immediate-release morphine 30 mg orally.

What condition may indicate the need for hemodynamic monitoring?

Shock Conditions that may indicate the need for hemodynamic monitoring include hypotension, hypertension, cardiac failure, shock, hemorrhage, respiratory failure, fluid imbalances, and sepsis.

A young adult patient with metastatic cancer, who is very close to death, appears restless. The patient keeps repeating, "I am not ready to die." Which action is best for the nurse to take?

Sit at the bedside and ask if there is anything the patient needs.

The patient's systolic blood pressure suddenly drops, and the diastolic pressure is suddenly elevated. Which situation is the most likely cause?

The pressure bag is pressurized to 300 mm Hg An overdamped waveform results in a falsely low systolic pressure and a falsely high diastolic pressure. The flush bag should have fluid with a pressure of 300 mm Hg. If the patient was septic or dehydrated, it is unlikely the blood pressure would drop so quickly with an elevated diastolic pressure.

What action taken by the nurse decreases the risk of error in managing lines? A client has been diagnosed with cardiomyopathy. Cardiac pressure and arterial pressure are being monitored. For this patient, which transducer system is the most convenient and easy to use?

Triple-pressure transducer system The triple-pressure transducer system allows monitoring of the patient's PA, RA, and arterial pressure. A triple-pressure transducer system is commonly used to measure pressure from the arterial and PA catheters. With the use of this system, arterial pressure, PA pressure, and RA pressure can be obtained.

A client who uses a fentanyl patch for chronic abdominal pain caused by ovarian cancer asks the nurse to administer the prescribed hydrocodone tablets, but the patient is asleep when the nurse returns with the medication. Which action is best for the nurse to take?

Wake the patient and administer medication

An 81-yr-old client who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. The nurse will plan to?

inform the receiving nurse and then transfer the patient. The patient's history and symptoms most likely indicate delirium associated with the sleep deprivation and sensory overload in the ICU environment. Informing the receiving nurse and transferring the patient is appropriate

The intensive care unit (ICU) nurse educator will determine that teaching about arterial pressure monitoring for a new staff nurse has been effective when the nurse:

positions the zero-reference stopcock line level with the phlebostatic axis.

The wife of a patient who is hospitalized in the critical care unit following resuscitation for a sudden cardiac arrest at work demands to meet with the nursing manager. She states, "I want you to reassign my husband to another nurse. His current nurse is not in the room enough to make sure he is okay." The nurse recognizes that this response most likely is due to the wife's:

sense of loss of control of the situation.

A conflict arises among different family members and the healthcare provider regarding decisions to be made about life sustaining treatment for a comatose client. The client did not designate a surrogate. Which of the following resources is the most helpful in this situation?

The organization's resolution process

An experienced nurse is teaching a new nurse about the setup with arterial pressure based cardiac output (APCO) monitoring. The new nurse asks how much fluid to squeeze into the drip chamber prior to flushing the line. Which response by the experience nurse is the best?

"Fill the drip chamber halfway so that you can still see fluid flowing when you flush."

A meeting of the client and family members is called to discuss end-of-life planning, including withholding and withdrawing life sustaining treatment. The overall goal of any discussion of withholding or withdrawing treatment is to meet the wishes of whom?

The patient

When monitoring the effectiveness of treatment for a client with a large anterior wall myocardial infarction, the most pertinent measurement for the nurse to obtain is?

pulmonary artery wedge pressure (PAWP).

Casting judgement is a barrier to effective communication among team members. Which statement would be considered a judgmental statement?

"I don't think you need to do that."

The nurse is caring for a patient with heart failure who is undergoing arterial-pressure based cardiac output (APCO) monitoring. Daily weights are obtained as part of the patient's management plan. A nursing student asks if the patient's daily weight needs to be entered into the APCO system. Which response by the nurse is best?

"No, the APCO uses the patient's dry weight, fluctuations in weight due to fluid loss of gain should be discounted for the purposes of the APCO." The APCO system calculates the BSA based on the patient's height and dry weight, discounting fluid weight gain or loss. The daily weight is not entered in to the APCO system as the dry weight is used to form the basis of the calculations.

After withdrawing of care a client is showing a decrease in all body system functions except for a heart rate of 124 beats/min and a respiratory rate of 28 breaths/min. Which statement, if made by the nurse to the client's family member, is most appropriate?

"These vital signs are an expected response now but will slow down later."

A client who has been successfully resuscitated after developing ventricular fibrillation asks the nurse about what happened. The most appropriate response by the nurse is which of the following?

"You had a serious abnormal heart rhythm, which treatment was able to reverse"

The most important outcome of effective communication is to:

reduce patient errors

Which question asked by the nurse will give the most information about the client's metastatic cancer pain? A. "How would you describe your pain?" B. "Do you have nausea with your pain?" C. "Do you remember the onset of your pain?" D. "Is your pain chronic?"

A. "How would you describe your pain?" Because pain is a multidimensional experience, asking a question that addresses the patient's experience with the pain will elicit more information than the more specific information asked in the other three responses.

What is the purpose of a living will? A. Allows individuals to state what measures should be taken to prolong life when a condition is terminal B. To identify who can make medical decisions for the patient when they are unable to C. For individuals to express when they want treatment stopped or when to initiate a DNR D. Allows patients to speak about their opinions of treatments given during life threatening conditions

A. Allows individuals to state what measures should be taken to prolong life when a condition is terminal A living will is a document that identifies treatments a patient would or would not want in specific end-of-life situations. Most are specific to terminal illness, a permanent state of unconsciousness, or a persistent vegetative state. A living will does not identify who will make decisions for the patient, when to stop treatment, or when to initiate a "do not resuscitate" order for the patient.

Continuous monitoring of the CVP waveform reveals a marked change from 7 mm Hg to 1 mm Hg. After the nurse re-levels the transducer, the reading is still 1 mm Hg. Which of the following should be the nurses next step? A. Assess the clients blood pressure, heart rate and urine output in preparation of notifying the healthcare provider. B. Re-level the transducer again before further intervention. C. Administer bolus of D5W to improve blood pressure. D. Reassess CVP waveform in 10 minutes.

A. Assess the clients blood pressure, heart rate and urine output in preparation of notifying the healthcare provider.

The family of your critically ill patient tells you that they have not spoken with the physician in over 24 hours, and they have some questions that they want clarified. During morning rounds, you convey this concern to the attending intensivist and arrange for her to meet with the family at 4:00 PM in the conference room. Which competency of critical care nursing does this represent? A. Collaboration with patients, families, and team members B. Duty to inform healthcare providers C. Understanding of the nurses' scope of practice D. Utilization of resources

A. Collaboration with patients, families, and team members

Which statement is the correct regarding removal of a femoral arterial catheter? A. Removing a catheter from a femoral artery requires applying pressure longer than for other sites B. Remove the catheter and immediately place dressing C. Warn patient before removal that they may see a lot of blood D. Assess distal pulses before removal

A. Removing a catheter from a femoral artery requires applying pressure longer than for other sites. To obtain hemostasis after removing a femoral arterial catheter, the nurse will need to apply direct pressure longer than for other sites because the catheter was in a large artery. Direct pressure must be applied during removal and until hemostasis is achieved once the catheter is removed from any catheter site. All arterial catheter sites require that a pressure dressing be applied once the catheter is removed.

Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate action? A. The right hand is cooler than the left hand. B. The cuff pressure and arterial line pressure differ by 7 mm Hg. C. The flush solution bag is inflated to 300 mm Hg D. The transducer is parallel with the umbilicus

A. The right hand is cooler than the left hand. The change in temperature of the left hand suggests that blood flow to the left hand is impaired. The arm cuff pressure and intravascular pressure can differ by 5-10 mm Hg without altering clinical management.

A patient with terminal cancer-related pain and a history of opioid abuse complains of breakthrough pain 2 hours before the next dose of sustained-release morphine sulfate (MS Contin) is due. Which action should the nurse take first? A. Educate the patient about the risk of respiratory depression with opioids B. Administer the prescribed PRN immediate-acting morphine C. State the best dose of pain medication is in 2 hours and the nurse will return to administer the medication then D. Utilize distraction techniques to help the patient forget about their pain until their next dose is due

B. Administer the prescribed PRN immediate-acting morphine. The patient's pain requires rapid treatment, and the nurse should administer the immediate-acting morphine.

The nurse cares for a terminally ill patient who is experiencing pain that is continuous and severe during the withdrawal of care. How should the nurse schedule the administration of opioid pain medications? A. Opioids should only be administered if pain level is greater than 7 B. Advocate for around-the-clock routine administration of analgesics C. Scheduled as PRN D. Only schedule opioids that do not put the patient at risk for respiratory depression

B. Advocate for around-the-clock routine administration of analgesics.

A new nurse is under the supervision of a preceptor. The preceptor knows the nurse understands how to maintain hemostasis while removing an arterial catheter when the nurse performs which action? A. Places a tourniquet proximal to the insertion site prior to removing the catheter B. Applies proximal pressure while removing the catheter C. Applies distal pressure while removing the catheter D. Secures tight dressing over insertion sight prior to removing the catheter

B. Applies proximal pressure while removing the catheter The nurse should maintain proximal pressure while removing the arterial catheter and then immediately apply firm pressure over the insertion site as the catheter is removed to initiate the coagulation process

Family members have a need for information. Which interventions best assist in meeting this need? (Select all that apply) A. Provide family members and friends with the phone number for the unit so they can call in to request medical information B. Provide a daily update of the patient's progress C. Offer to provide all family members with a printed copy of the patient's chart D. Facilitate communication with the intensivist E. Offer your personal number so you can provide immediate updates

B. Provide a daily update of the patient's progress D. Facilitate communication with the intensivist The nurse can give a status report related to the patient's condition and current treatment plan as well as ensure that the family has daily meeting time with the intensivist for an update on diagnoses, prognoses, and the like.

Which nursing actions for the care of a dying patient can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)? A. Perform admission assessment B. Provide postmortem care to the patient. C. Encourage the family members to talk with and reassure the patient. D. Create a care plan E. Administer the prescribed morphine sulfate sublingual as necessary for pain control.

B. Provide postmortem care to the patient. C. Encourage the family members to talk with and reassure the patient. E. Administer the prescribed morphine sulfate sublingual as necessary for pain control. Medication administration, psychosocial care, and postmortem care are included in LPN/LVN education and scope of practice.

When practicing effective patient communication, the nurse leader should demonstrate what actions? (Select all that apply.)

Being concise when providing patient education. Speaking in a clear voice. Being concrete when communicating with patients. Ensuring that communication with patients is complete. Providing courteous communication when interacting with patients.

A client who has had good control for chronic pain using a fentanyl patch reports rapid onset pain at a level 9 (0 to 10 scale) and requests "something for pain that will work quickly." How will the nurse document the type of pain reported by this client?

Breakthrough

The nurse manager attends a conference, and the topic of discussion is leadership styles. The nurse is seeking a leadership style that will empower staff to achieve excellence. Which leadership style should the nurse select to achieve this goal? A. Autocratic B. Transformational C. Democratic D. Laissez-faire

C. Democratic Democratic styles empower staff toward excellence because this style of leadership allows nurses an opportunity to grow professionally.

A client is making his end-of-life wishes known. He understands that his heart failure is in the final stage. He states that he has had a full life and that his disease would no longer allow a quality life. He does not wish to prolong the inevitable. What can be said about this client? A. The client is upset about his prognosis B. The client is tired of fighting his disease and wants to give up C. The client has the capacity to make his own decisions D. The client does not comprehend his disease process and is making an uninformed decision

C. The client has the capacity to make his own decisions A patient's decision-making capacity is determined by his or her ability to understand relevant information, make judgments about information considering his or her personal values, intend a certain outcome, and communicate decisions to practitioners. This patient's actions and discussions demonstrate these abilities. The patient took the initiative to discuss the issue, verbalized an understanding of his heart failure considering his values and desires, and decided that he did not want to prolong therapy in light of the outcome.

The nurse is caring for a patient who has an arterial catheter in the left radial artery for arterial pressure- based cardiac output (APCO) monitoring. Which information obtained by the nurse requires a report to the health care provider? A. Cardiac output is 5 L/min B. Mean arterial pressure is 71 mm HG C. There is redness at the catheter insertion site D. Respiratory rate is 12 after opioid administration

C. There is redness at the catheter insertion site. Redness at the catheter insertion site indicates possible infection.

The nurse assesses that a client with terminal cancer who complains of severe pain has a respiratory rate of 11 breaths/min. Which action should the nurse take? A. Administer Naloxone for respiratory depression B. Call the provider to recommend NSAIDs for pain relief C. Titrate the prescribed morphine dose up, until the patient indicates adequate pain relief. D. Educate patient on risk of respiratory depression with opioid use

C. Titrate the prescribed morphine dose up until the patient indicates adequate pain relief. The goal of opioid use in terminally ill patients is effective pain relief regardless of adverse effects such as respiratory depression

To provide appropriate care and be able to answer questions regarding medications administered at the end of life, the nurse needs to understand which concept? A. Home medications should be continued B. Palliative care and medications should always be administered C. Uncontrolled pain is an emergency D. Opioid administration should be closely monitored and limited

C. Uncontrolled pain is an emergency Even at the end of life, uncontrolled pain is an emergency, and the entire health care team is responsible for providing pain relief.

Which patient with pain should the nurse assess first?

Client who returned from the OR 2 hours ago and has a respiratory rate of 8

A client who has been in the intensive care unit for 4 days has disturbed sensory perception from sleep deprivation. Which action should the nurse include in the plan of care?

Cluster nursing activities so that the patient has uninterrupted rest periods.

When caring for a client with a left radial arterial line, the nurse notes that the left hand is cool and the capillary refill time in the finger is 6 seconds. What is the appropriate action by the nurse?

Contact the health care provider.

Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP) when caring for a client who is using a fentanyl patch and a heating pad for treatment of chronic back pain while in the ICU?

Count the respiratory rate every 2 hours.

Which action should the nurse take when the low-pressure alarm sounds for a client who has an arterial line in the left radial artery? A. Silence the Alarm B. Assess capillary refill on all extremities C. Monitor blood pressure for 5 minutes D. Assess for cardiac dysrhythmias

D. Assess for cardiac dysrhythmias The low-pressure alarm indicates a drop in the patient's blood pressure, which may be caused by cardiac dysrhythmias

The nurse is assigned to care for a patient who is a non-native English speaker. What is the best way to communicate with the patient and family to provide updates and explain procedures? A. Write information down on a notepad B. Use google translate on your phone C. Ask the patient's English speaking daughter to translate D. Contact the hospital's interpreter service for someone to translate

D. Contact the hospital's interpreter service for someone to translate. The best approach when communicating with someone whose primary language is not English is to contact the interpreter services of the agency. These individuals are trained and knowledgeable

After cannulation of the left femoral artery for arterial pressure based cardiac output (APCO) monitoring, which assessment should the nurse perform immediately and document? A. Capillary refill in the left lower extremity B. Skin turgor C. Heart rate and blood pressure D. Pulse in the affected extremity

D. Pulse in the affected extremity The nurse should assess the pulse by palpation to evaluate perfusion to the limb. Absence of a pulse in the affected extremity warrants immediate intervention.

The nurse admits a terminally ill patient to the hospital. What is the first action that the nurse should complete when planning this patient's care?

Determine the patient's wishes regarding end-of-life care.

When evaluating a client with a central venous catheter, the nurse observes that the insertion site is red and tender to touch, and the patient's temperature is 101.8° F. What should the nurse plan to do?

Discontinue the catheter and culture the tip.

The nurse is caring for a client who is unresponsive after withdrawing of care who now has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be appropriate?

Document Cheyne-Stokes respirations. Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep and rapid breaths. Cheyne-Stokes respirations are expected in the last days of life and are not position dependent

A nurse assesses a postoperative client 2 days after open heart surgery. What findings indicate that the client requires better pain management (select all that apply)?

Elevated temperature Poor cough effort Confusion Shallow breathing

The nurse is setting up the monitor for measuring a client's PA pressure. What action should the nurse take to ensure the correct measurement is obtained

Ensure the correct waveform is selected on the monitor

The nurse is caring for a client undergoing arterial-pressure based cardiac output (APCO) monitoring. How often should the hemodynamic monitoring system be changed?

Every 96 hours

Which intervention is appropriate to assist the patient to cope with admission to the critical care unit?

Explaining all procedures in easy-to-understand terms

To remove the air from the IV flush bag, the nurse spikes the inverted IV flush bag, keeping the drip chamber upright. Which action is the next step the nurse should perform to remove the air?

Gently squeeze the air out of the bag while activating the flush system.

Following surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take?

Increase the IV fluid infusion per protocol

The nurse is setting up a disposable pressure transducer system. What action should the nurse take to ensure accurate management of the solution used?

Label the bag with the date and time and initial the label

What action taken by the nurse decreases the risk of error in managing lines?

Labeling the tubing

A student is caring for a client who suffered massive blood loss during surgery. How does the student correlate the blood loss with the client's mean arterial pressure (MAP)?

Lower blood volume lowers MAP. Lower circulating volume equates to a lower BP and MAP. When the body compensates it vasoconstricts to raise MAP not decrease. Loss of volume equals decreased cardiac output.

The health care provider orders a patient-controlled analgesia (PCA) machine to provide pain relief for a client with acute surgical pain who has never received opioids before. Which nursing actions regarding opioid administration are appropriate at this time (select all that apply)?

Monitor for therapeutic and adverse effects of opioid administration. Teach the patient about how analgesics improve postoperative activity levels.

The nurse is preparing the equipment for arterial pressure based cardiac output (APCO) measurement. When leveling the transducer, which anatomical landmark should be used as a reference point?

Phlebostatic axis

While withdrawing life sustaining treatments the client shows signs and symptoms of discomfort. Which action should the nurse take next?

Rapidly titrate analgesic and anxiolytic doses.

A patient who is using both a fentanyl (Duragesic) patch and immediate-release morphine for chronic cancer pain develops new-onset confusion, dizziness, and a decrease in respiratory rate. Which action should the nurse take first?

Remove the fentanyl patch.

While assisting with the placement of a pulmonary artery (PA) catheter, the nurse notes that the catheter is correctly placed when the balloon is inflated, and the monitor shows a?

typical PA wedge pressure (PAWP) tracing.