NUR 425 Exam 1 Q uestions and
Answers
Normal vital signs in adults ✅Blood pressure: 90/60 mm Hg to 120/80 mm Hg.
Breathing: 12 to 18 breaths per minute.
Pulse: 60 to 100 beats per minute.
Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C)/average 98.6°F (37°C)
Spo2: 95-100%
What can inadequate pain management and unrelieved pain lead to? ✅agitation,
anxiety, delirium and reduced healing
The pain assessment gold standard is ✅a verbal report from the patient
-if the patient can report their pain then that IS their pain level (even in cases of
delirium)
Pain assessment tools that can be used if the patient is non-verbal ✅CPOT (Critical
Care Pain Observation Tool)
BPS (Behavior Pain Scale)
What are signs of pain that can be assessed by the nurse? ✅-Tightened facial
expression, grimacing
-Restless and retracted body movements
-Fighting the ventilators
-Increased respiratory rate (over 20)
-Increased heartbeat (Over 100)
-Hypertension (Over 120/80)
An important nursing responsibility related to pain is to
A) leave the patient alone to rest.
B) help the patient appear to not be in pain.
C) believe what the patient says about the pain.
D) assume responsibility for eliminating the patient's pain. ✅c) believe what the patient
says about the pain.
Which of the following is NOT a likely sign of pain in a nonverbal patient?
A) Eyes clenched shut when turning the patient
B) Decreased respiratory rate
C) Patient resists bending of her elbow when you try to contract her arm
,D) Heart rate of 120 in a 54 yeterm-9ar old male ✅b) Decreased respiratory rate
What steps do we take when treating pain in the ICU? ✅1) Assess- make sure that the
cause isn't immediately reversible (i.e.: positioning)
2) use drug and non-drug therapies (Music, massage, aromatherapy,
positioning/mobility, meditation)
3) Continuously evaluate
What should you remember about continuous IV drips for analgesia in the ICU? ✅-You
can titrate the medication based on the patient's pain score
-This requires frequent assessment of pain, utilizing guardrails in the IV pump and
always checking your math
What do you need to document related to pain? ✅both the pain assessment and the
infusion rate (included in I's & o's)
Fentanyl ✅Indications: controls moderate to severe pain, can be used as an adjunct to
general or regional anesthesia, often used with a sedative
Side effects: sedation, blurred vision, muscle rigidity, n/v
-Signs of overdose: Signs of overdose include trouble breathing or shallow respirations;
tiredness, extreme sleepiness, or sedation; inability to think, talk, or walk normally; and
faintness, dizziness, or confusion
Nursing considerations: IV onset is 1 minute, take vitals, watch for LOC changes and
respiratory rate (less than 10), evaluate the response
You walk into your intubated patient's room with an IV fentanyl drip at 25mcg/hour who
presents with the following:
Heart rate: 130
BP: 140/90
RR: 29
Which of the following should the nurse do first?
A) Ask the patient to rank her pain on a scale of 0-10
B) Increase the fentanyl drip rate per protocol
C) Call the physician for additional pain medication orders
D) Get a music therapy consult
E) Look at the patient's facial expression and muscle tension ✅e) Look at the patient's
facial expression and muscle tension
You walk into your intubated patient's room with an IV fentanyl drip at 25mcg/hour who
presents with the following:
Heart rate: 130
BP: 140/90
RR: 29, ventilator alarming
,Hands clenched, brow narrowed, patient eyes open and looking at you anxiously.
Which of the following should the nurse do first?
A) Ask the patient "Are you in pain?"
B) Stop the fentanyl drip and request orders for a new analgesic
C) Increase the fentanyl drip rate per protocol
D) Tell the patient to calm down
Get a music therapy consult ✅a) Ask the patient "Are you in pain?"
Why do we sedate in the ICU? ✅Patient safety, minimizing discomfort and pain during
procedures (sedatives are not always analgesic though), minimize physical
disturbances, maximize amnesia when appropriate, control behavior (reduce
anxiety/stress in severe situations)
Midazolam ✅Indications: benzo of choice for short term sedation, takes a little bit
longer to work and wear off
Side effects: retrograde amnesia, respiratory depression
Nursing considerations: can be stored in your patient's adipose tissue and accumulate if
they have prolonged sedation, potential tolerance and withdrawal
Propofol ✅Indications: has a rapid onset/offset, useful in transition from long acting
sedative during patient recovery
Side effects: hypotension, decreased SVR and contractility, respiratory depression
Nursing considerations: this med is a lipid so watch their lab values in prolonged uses
(maybe consider another med if they have cardiac problems) nurses cannot give this IV
push unless the doctor is occupied and it is an emergent situation
Lowers BP so it decreases preload and slightly decreases afterload
What are some problems that can occur with sedation? ✅Tolerance can build up over
time, withdrawals can occur when the med is stopped, reduced REM sleep time,
increased chance for delirium
Over sedation: increased time on the ventilator and increased length of stay
Undersedation: hyper catabolism, immunosuppression, hypercoagulbility, SNS
response
What are the 2 sedation assessment tools? ✅RASS (Richmond Agitation-Sedation
Scale)
Ramsay scale
, RASS sedation scale ✅+4 on the scale is combative (violent, immediate danger to
staff) and -5 is unarousable (no response to physical stimulation). Doctors will give
orders to medicate based on what level they want their patient to be
Ramsay Scale Scoring Sedation ✅1 - Anxious/agutated or restless, or both
2 - Cooperative, orientated, and tranquil
3 - Drowsy, but responds to commands
4 - Asleep, brisk response to light glabellar tap or loud auditory stimulus
5 - Asleep, sluggish response to light glabellar tap or loud auditory stimulus
6 - Asleep and unarousable
What is sensory perception? ✅How humans interact with their environment, perceiving
stimulation through the 5 senses in and outside of the body
Definition of delirium ✅A state of temporary but acute mental confusion, is a common,
life-threatening syndrome. Delirium affects as many as 50% of people older than 65
years who are hospitalized, and as many as 80% of patients in the ICU
What are some causes for delirium? ✅sleep deprivation, medications (ie: sedatives),
sensory overload from the environment, (ie: invasive lines/tubes), anxiety, disease
processes (ie: hypoxia, dementia, shock, kidney failure)
Mnemonic for causes of delirium ✅D - DEMENTIA, DEHYDRATION,
E - ELECTROLYTE IMBALANCES, EMOTIONAL STRESS,
L - LUNG, LIVER, HEART, KIDNEY, BRAIN,
I - INFECTION, INTENSIVE CARE UNIT,
R - DRUGS,
I- INJURY, IMMOBILITY,
U- UNTREATED PAIN, UNFAMILIAR ENVIRONMENT,
M- METABOLIC DISORDERS
Sedatives and delirium ✅-Sedatives can cause delirium because they reduce the
amount of REM sleep and alter the sleep-wake cycle
-They are given to patients with delirium if they need to be quickly calmed down (i.e.: if
they are combative to nurses)
