NUR 425 EXAM 1 2024-2025 WITH ACTUAL
CORRECT QUESTIONS AND VERIFIED
DETAILED ANSWERS |FREQUENTLY
TESTED QUESTIONS AND SOLUTIONS
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A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T
wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves or definable
QRS complexes. Instead there are coarse wavy lines of varying amplitude. The nurse assesses this
rhythm to be:
A. Ventricular tachycardia
B. Ventricular fibrillation
C. Atrial fibrillation
D. Asystole
B (Ventricular fibrillation is characterized by irregular, chaotic undulations of varying amplitudes.
Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results
from electrical chaos in the ventricles.)
While caring for a client who has sustained an MI, the nurse notes eight PVCs in one minute on the
cardiac monitor. The client is receiving an IV infusion of D5W and oxygen at 2 L/minute. The nurse's first
course of action should be to:
A. Increase the IV infusion rate
B. Notify the physician promptly
C. Increase the oxygen concentration
D. Administer a prescribed analgesic
B (PVCs are often a precursor of life-threatening dysrhythmias, including ventricular tachycardia and
ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate
greater than 5 or 6 per minute in the post MI client, the physician should be notified immediately.
More than 6 PVCs per minute is considered serious and usually calls for decreasing ventricular
irritability by administering medications such as lidocaine. Increasing the IV infusion rate would not
decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first
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,course of action; rather, the nurse should notify the physician promptly. Administering a prescribed
analgesic would not decrease ventricular irritability.)
You are caring for a patient following a motor vehicle accident in the Intensive Care Unit at your
hospital. Which of the following would not be a primary concern for you in the critical care setting?
a. The patients' sleep cycle may become disrupted in the ICU.
b. The patient may develop dementia due to an altered sleep/wake cycle in the intensive care unit.
c. The patient may develop anxiety due to the fear of being in a foreign environment, pain, or loss of
control.
d. The patients' communication skills are impaired due to possible sedation and endotracheal tubes.
B (B is incorrect because the patient will not develop dementia in the ICU, but they may develop
delirium due to sedation and an altered sleep/wake cycle. A is true because sedatives disrupt a
patients' sleep. In addition, there can be a lot of noise in the ICU from alarms, and the patient may
need consistent assessments, even throughout the night which potentially could wake up the patient
every time. C is correct because anxiety is common in an ICU patient--they are afraid because they
don't know where they are, they're confused, the ICU is fast paced, they are out of control, and they
may be in pain. D is correct because it is certainly possible that the patient will not be able to
communicate to the nurse. The patient may be sedated so they are not awake and alert, and if they
are sedated they will have an endotracheal tube so they will not be able to speak even if they are
alert.)
Which of the following would not be considered a cause of anxiety with the patient in an intensive care
unit, according to the lecture?
a. Fear
b. Loss of control
c. Mental health issues
d. Pain
e. Intense pace of the unit
f. Foreign environment
C
Which of the following would not be considered a cause of communication difficulties with the critical
care patient, according to the lecture?
a. Diuretics
b. Sedatives
c. Paralytics
d. Endotracheal tubes
e. Altered level of consciousness
f. The patient's disease process
A (Diuretics unlikely would cause the patient to have difficulty communicating with the nurse, or vice
versa.)
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,You are a nurse preceptor teaching several nursing students about the concept of delirium in the ICU.
Which of the following statements made the student is a true statement about delirium?
a. "Delirium is synonymous with dementia."
b. "Delirium cannot be caused by medications."
c. "Delirium is a chronic problem."
d. "Delirium can be caused by sleep deprivation, sensory overload, anxiety, and disease processes."
D (D is correct because these are accurate causes of delirium. Sleep deprivation can make the patient
very confused. Sedatives can cause delirium due to it altering their sleep-wake cycle. Invasive lines
and tubes can cause a sensory overload in the patient. Hypoxia can also precipitate delirium. Delirium
and dementia are completely different. Dementia is a chronic condition that is a slow onset. Delirium
is an acute problem characterized by altered mentation, psychomotor behaviors (restlessness,
lethargy) and an altered sleep-wake cycle (night time agitation.)
Which of the following would a patient most likely exhibit that has delirium? Select all that apply.
a. Night time agitation
b. Attentiveness
c. Short attention span
d. Irritability
e. Long term memory loss
A C D (Characteristics of delirium include:
-Delusions
-Short term memory loss
-Distractibility/short attention span
-Restlessness
-Lethargy
-Night time agitation)
You are caring for an intubated patient in the intensive care unit. The patient is awake but groggy from
the sedation. To assess for pain, which of the following techniques performed by the nurse would be
inappropriate for this situation?
a. The nurse asks the patient, "Are you in pain?"
b. The nurse uses the CPOT scale or BPS tool.
c. The nurse ignores the patient's vital signs because it is not a definitive indicator that the patient is in
pain.
d. The nurse checks the patients' glucose levels and if their pupils are dilated.
C (C is incorrect because when a patient is in pain, their vital signs can certainly be elevated. The nurse
should use this as an indicator for pain, but the nurse should always reassess further to determine if
there is another cause for the vital sign elevation. Using the Critical Care Pain Observation Tool or
Behavior Pain Scale is appropriate to assess pain. Asking the patient if they are in pain is a yes or no
question, so this is appropriate for a patient who in intubated and cannot speak. When a patient is in
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, pain, their sympathetic nervous system activates, which can increase glucose levels, blood pressure,
pulse, cause pupillary dilation, anxiety, goosebumps, and sweating.)
The nurse walks into a patient's room and notices that they have a grimace on their face and their heart
rate is elevated. Which of the following actions is most appropriate for the nurse to do first in this
situation?
a. Administer PRN morphine 2 mg IV for pain greater than 6 on a scale of 0-10.
b. Call the physician immediately.
c. Tell the patient that everything is going to be okay.
d. Further assess the patient to determine if pain is causing grimacing and increased heart rate.
D (D is the most correct because the nurse should always further assess the patient! You should not
automatically assume that the patient is in pain. There could be other causes for the grimacing and
fast heart rate, such as a syringe under their back. It is not necessary to call the physician immediately,
but if the patients' pain persists and is not relieved with medication, that may be an indicator to call
the physician.)
What is the purpose of sedation?
To decrease level of consciousness, establishing a state of calm
You are caring for a patient in the ICU that is exhibiting signs of delirium. Which of the following
interventions made by you, the nurse, would be inappropriate to help treat the delirium?
a. You put up a sign in the patients room that says, "You are at ASU hospital."
b. You move the patient to a room near the nurses stations.
c. You assess the cause for the delirium and treat it.
d. You provide frequent neuro assessments throughout the night to monitor the patient.
D (D is least appropriate because the nurse should try to cluster care when possible to promote sleep.
Interrupting the patients' sleep throughout the night would not help treat the patients' delirium.
Putting up a sign is appropriate because it helps orient them. Moving them to a room near the nurses
station is appropriate because it will help the nurse monitor and keep a close eye on them. Assessing
the cause of the delirium is extremely important in treating it because once the underlying cause is
identified, the delirium will begin to cease.)
You are caring for a patient in the ICU that is exhibiting signs of delirium. Which of the following
interventions made by you, the nurse, would be inappropriate to help treat the delirium?
a. You delay the patient becoming mobile because they are more at risk for falls when they have
delirium.
b. You reduce noise as much as possible.
c. You cluster care when possible.
d. You encourage family engagement with the patient care.
A (Early mobility is important with treating and preventing delirium.)
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