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NUR 425 CC Exam 1 Test Questions and Correct Answers $9.99   Add to cart

Exam (elaborations)

NUR 425 CC Exam 1 Test Questions and Correct Answers

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  • Course
  • NUR 425
  • Institution
  • NUR 425

Decreased sleep leads to... increased risk for delirium Most common problem in ICU patients anxiety: threat to health/life, loss of control of body functions, foreign environment, lots of noise, pain, can't communicate How to promote sleep in ICU scheduled rest p periods, dim lights at night, pro...

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  • September 9, 2024
  • 9
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • NUR 425
  • NUR 425
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twishfrancis
NUR 425 CC Exam 1 Test Questions and
Correct Answers
Decreased sleep leads to... ✅increased risk for delirium

Most common problem in ICU patients ✅anxiety: threat to health/life, loss of control of
body functions, foreign environment, lots of noise, pain, can't communicate

How to promote sleep in ICU ✅scheduled rest p periods, dim lights at night, provide
eye mask/ear plugs, open curtains during day, take measurements without disturbing
patient, comfort measures (benzos)

Causes of delirium ✅sleep deprived, meds, sensory overload, anxiety, disease
processes (hypoxia)

Signs of delirium ✅altered mental status, psychomotor. Behaviors (restless/lethargic),
altered sleep/wake cycle, inattention

ABCDEF bundle for ICU management ✅A: assess, prevent, manage pain by using
tools to be used in daily patients. B: both spontaneous trials and breathing, provide
powerful meds when needed, but stopping to prevent unwanted side effects. C: choice
of analgesia and sedation, using evidence to assess safest agents to use and ones to
avoid in a patient. D: delirium: assess, prevent, and manage. E: early mobility and
exercise to decrease delirium, decrease days on mechanical ventilation, and decrease
ICU hospital stay. F: family empowerment: open communication and clear e
expectations about recovery

Which assessment is used for delirium in ICU? ✅CAAM-ICU: confusion assessment
method for ICU

Common meds that are titrated ✅vasoactive agents, analgesics, sedatives.

Info in a titration med order ✅name, route, initial infusion rate, incremental units rate
can be increased/decreased, frequency for incremental doses, max rate, clinical
endpoint explained.

What response does pain elicit? ✅sympathetic nervous system

Cutaneous stimulation ✅heat, cold, vibration, massage (back massage promotes
sleep and relaxation), TENS (transcutaneous nerve stimulation)

, Sedation indications in ICU ✅to minimize discomfort/pain in procedures, safety,
minimize psychological disturbances, maximize amnesia if appropriate, control behavior

Common sedation drugs ✅midazolam and propofol

Common reasons for sedation ✅mechanical ventilation/reduce external stimuli from
stressing out an unstable patient

Midazolam ✅benzo of choice. Potential for tolerance/withdrawal, anterograde
amnesia, watch out for respiratory depression

Propofol ✅rapid offset, (lipid-watch triglycerides and cholesterol levels), watch out for
hypotension and Resp. Depression

Goal RAAS ✅0 to -2

Dexmedetomidine (Precedex) ✅alpha adrenergic receptor agonist in ICU for sedation

Best practice for sedation ✅control pain before sedation, because this may eliminate
need to sedate if pain med calms them down. Sedation interruptions/light target
sedation , non-pharm interventions to promote sleep, control light/noise, cluster care,
decrease stimuli at night

S/P ✅status post (talking about the condition that indicated treatment). Patient has
already experienced something medical

Intubated patient has IV fentanyl drip of 25 mcg/hr with: HR: 130, BP: 140/90, RR: 29,
ventilator alarming. Hands clenched, brow narrowed, patient eyes open and looking at
you anxiously. What should you do first? ✅ask the patient: "are you in pain?" want to
gather further assessment data

What type of problem? Q: everything looks normal, but HR is over 100 bpm or less than
60 bpm ✅SA node problem

What type of problem?: P-wave absent/abnormal, but QRS is normal. ✅atrial problem
(ex: SVT, a-fib, PAC)

What type of problem?: PR interval is too long or inconsistent, ratio of P-waves to QRS
interval is abnormal ✅AV node problem! The ratio of P to QRS complexes is greater
than 1:1 in both 2nd and 3rd degree blocks

Problem?: QRS wider than 0.12 seconds/3 small boxes ✅ventricular problem! Ex: VT,
v-fib, pvcs

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