NUR 425 Exam 1 - Critical Care Unit Questions And Already Passed Answers.
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Course
NUR 425
Institution
NUR 425
If a patient is delirious and hitting you and pulling out their wires, do you give them more sedatives even though sedatives make delirium worse? - Answer Yes, because they are a danger to themselves and others. If they were delirious but pleasant you would try to avoid the sedatives.
Which o...
NUR 425 Exam 1 - Critical Care Unit
Questions And Already Passed Answers.
If a patient is delirious and hitting you and pulling out their wires, do you give them more sedatives even
though sedatives make delirium worse? - Answer Yes, because they are a danger to themselves and
others. If they were delirious but pleasant you would try to avoid the sedatives.
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 year old male - Answer b. Decreased respiratory rate
If a patient is already on phentenyol but have a CPOT of 7 and are grimacing, what do you want to do
before you give them more pain meds? - Answer assess everything first! are they laying on something?
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 - Answer 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
e. Get a music therapy consult - Answer a. Ask the patient "Are you in pain?"
Midazolam - Answer Benzo of choice. Anterograde amnesia. Stored in the body and can accumulate
over time and cause prolonged sedation. Respiratory depression, but not worried if on ventilator.
Potential for tolerance and withdrawal.
Propofol - Answer white lipid drug. Look out for hyperlipidemia. Rapid onset and rapid offset! Need to
intubate the patient and be ready for breathing problems. Hypotension. Nurse cannot push unless under
doctor supervision.
Fentenyl - Answer Analgesia with rapid onset and offset. Respiratory depression. Used with sedatives.
Ativan - Answer sedative that decreases REM sleep
CAM-ICU scale - Answer assessment scale for delirium
RASS - Answer sedation scale
, CPOT - Answer critical care pain observation tool
BPS - Answer Behavior pain scale
Which of the following patients is MOST likely to be experiencing delirium?
a. A 94 year old female who answered "September 5" instead of "September 15" when asked what day
it is
b. A 34 year old male diagnosed with a right femur fracture who is talking in his sleep after receiving
1mg of Dilaudid IV
c. An 81 year old male who was alert and oriented x4 yesterday, but appears upset with you today . He is
convinced you are the city police and that you are trying to take him back to jail.
d. A 79 year old female admitted with a GI bleed who you cared for yesterday that does not remember
your name. She also thought it was 8pm instead of 8am before you brought in her breakfast tray. -
Answer c. An 81 year old male who was alert and oriented x4 yesterday, but appears upset with you
today . He is convinced you are the city police and that you are trying to take him back to jail.
Which of the following could be appropriate nursing interventions for the patient experiencing delirium?
(Select all that apply)
1. Frequently orient the patient
2. Monitor for potential risk factors such as dehydration, constipation, or pain
3. Ensure the patient always has an indwelling urinary catheter to reduce incontinence
4. Ensure the patient has any devices in place such as glasses or hearing aids
5. Wake the patient up frequently during the night to remind the patient of where he/she is
6. Provide the patient with puzzles, washcloths to fold, or a coloring book - Answer 1, 2, 4, 6
Which of the following is an appropriate assessment tool for delirium in the ICU?
Ramsey Scale
RAAS
CPOT
CAM-ICU - Answer CAM-ICU
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