TEST BANK For Understanding the Essentials of Critical Care Nursing, 3rd Edition by Perrin.pdf

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Test Bank for Understanding the Essentials of
Critical Care Nursing 3rd Edition Perrin
Chapters 1 - 19

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TEST BANK FOR UNDERSTANDING THE ESSENTIALS OF CRITICAL CARE
NURSING 3RD EDITION BY KATHLEEN PERRIN, CARRIE MACLEOD
TABLE OF CONTENT
1. What is Critical Care?
2. Care of the Critical Ill Patient
3. Care of the Patient with Respiratory Failure
4. Interpretation and Management of Basic Dysrhythmias
5. Cardiodynamics and Hemodynamic Regulation
6. Care of the Patient Experiencing Shock
7. Care of the Patient Experiencing Heart Failure
8. Care of the Patient Experiencing Acute Coronary Syndrome
9. Care of the Patient Following Traumatic Injury
10. Care of the Patient Experiencing an Intracranial Dysfunction
11. Care of the Patient With a Cerebral or Cerbrovascular Disorder
12. Care of the Critically Ill Patient Experiencing Alcohol Withdrawal and/or Liver Failure
13. Care of the Patient With an Acute Gastrointestinal Bleed or Pancreatitis
14. Care of the Patient with Problems in Glucose Metabolism
15. Care of the Patient with Acute Kidney Injury
16. Care of the Organ Donor and Transplant Recipient
17. Care of the Acutely Ill Burn Patient
18. Care of the Patient with Sepsis
19. Care of the ICU Patient at the End of Life

1
Perrin: Understanding the Essentials of Critical Care Nursing Chapter 1:
What is Critical Care?
MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the ques
1) Of the following patients, who should be cared for in a critical care unit? A patient: (Select all that apply.)
A) With an acetaminophen overdose
B) Suffering from acute mental illness
C) With chronic renal failure
D) With acute decompensated heart failure
ANSWER: A, D
Explanation: A) (Note: This requires multiple responses to be correct.)
Critical care units are co
- e
st
fficient units for caring for patients with specific organ
system failure. Although the organ failing in #4 is obvious, patients with acetaminophen overdose
often suffer liver failure as a consequence. #2 and #3 present patient concerns of a noncritical
nature.
Nursing Process: Evaluation
Cognitive Level: Analysis
Category of Need: Physiological Integrity–Physiological Adaptation

2
B) (Note: This requires multiple responses to be correct.)
- e
st
nature.
Nursing Process: Evaluation Cognitive
Level: Analysis
C) (Note: This requires multiple responses to be correct.)
- e
st
nature.
Level: Analysis
D) (Note: This requires multiple responses to be correct.)
- e
st
nature.
Level: Analysis

3
2) A hospital in a small rural town would be able to provide which level of care in the critical care unit?
A) Level I
B) Level II
C) Level III
D) It is unlikely that the hospital would have a critical care unit
ANSWER: C
Explanation: A) #1 and #2 describe more advanced and inclusive critical care abilities; #4 is not likely a
all because most hospitals have some critical care areas. Nursing
Process: Evaluation
Cognitive Level: Application
Category of Need: Safe, Effective Care Environment–Management of Care
B) #1 and #2 describe more advanced and inclusive critical care abilities; #4 is not likely a all because
most hospitals have some critical care areas.
Level: Application
C) #1 and #2 describe more advanced and inclusive critical care abilities; #4 is not likely a all because
Level: Application
D) #1 and #2 describe more advanced and inclusive critical care abilities; #4 is not likely a all because
Level: Application
3) A nurse employed in an "open" ICU would most likely be working with a:
A) Multidisciplinary team with physicians who are also responsible for patients on other units.
B) Multidisciplinary team that includes a physician employed by the hospital.
C) Physician in charge of patient care who is a specialist in critical care.
D) Primary care physician who must consult a critical care specialist.
ANSWER: A
Explanation: A) #2, #3, and #4 refer to "closed" ICUs.
Level: Analysis
B) #2, #3, and #4 refer to "closed" ICUs.
Level: Analysis
C) #2, #3, and #4 refer to "closed" ICUs.
Level: Analysis
D) #2, #3, and #4 refer to "closed" ICUs.
Level: Analysis

4
4) According to the Institute of Medicine, technology increases the likelihood of errors in critical care units when:
A) It relies heavily on human decisi-om
naking.
B) Devices are programmed to function without do u
- b
cl
h
eec ks.
C) It makes the workload seem overwhelming to health care providers.
D) There is uniform equipment throughout each facility.
ANSWER: B
Explanation: A) #1, #3, and #4 have not been identified to increase the likelihood of errors in the critica
care unit.
Level: Comprehension
B) #1, #3, and #4 have not been identified to increase the likelihood of errors in the critica care unit.
C) #1, #3, and #4 have not been identified to increase the likelihood of errors in the critica care unit.
D) #1, #3, and #4 have not been identified to increase the likelihood of errors in the critica care unit.

5
5) Which of the following is a common example of installing forcing functions or system level firewalls in order to
prevent errors?
A) Prior to administration of insulin, two nurses check the dose.
B) Prior to obtaining a medication, height, weight and allergies are recorded.
C) All medications are checked by two nurses prior to administration.
D) Undiluted potassium chloride is not available on critical care units.
ANSWER: D
Explanation: A) #1 and #3 are examples of avoiding reliance on vigilance; #2 is an example of utilizing
constraints.
Level: Application
Category of Need: Physiological Integrity–Pharmacological and Parenteral Therapies
B) #1 and #3 are examples of avoiding reliance on vigilance; #2 is an example of utilizing
constraints.
Level: Application
C) #1 and #3 are examples of avoiding reliance on vigilance; #2 is an example of utilizing
constraints.
Level: Application
D) #1 and #3 are examples of avoiding reliance on vigilance; #2 is an example of utilizing
constraints.
Level: Application

6
6) The increased use of technology in critical care units has resulted in which of the following
consequences for patient care?
A) Decreased risk of errors in patient care
B) Decreased therapeutic nur-sp
eatient communication
C) Improved overall patient satisfaction with care
D) Improved patient safety across the entire spectrum
ANSWER: B
Explanation: A) #1, #3, and #4 have not been demonstrated as outcomes resulting from increased
technology use.
Level: Application
B) #1, #3, and #4 have not been demonstrated as outcomes resulting from increased
technology use.
Level: Application
C) #1, #3, and #4 have not been demonstrated as outcomes resulting from increased
technology use.
Level: Application
D) #1, #3, and #4 have not been demonstrated as outcomes resulting from increased
technology use.
Level: Application

7
7) Completion of a preoperative checklist is an operationalized example of which of the following
recommendations issued by the Institute of Medicine?
A) Utilizing constraints
B) Simplifying key processes
C) Avoiding reliance on vigilance
D) Standardizing key processes
ANSWER: C
Explanation: A) #1, #2, and #4 are additional recommendations issued by the Institute of Medicine.
Level: Application
B) #1, #2, and #4 are additional recommendations issued by the Institute of Medicine. Nursing
Process: Evaluation
C) #1, #2, and #4 are additional recommendations issued by the Institute of Medicine. Nursing
Process: Evaluation
D) #1, #2, and #4 are additional recommendations issued by the Institute of Medicine. Nursing
Process: Evaluation

8
8) Which of the following actions should the nurse complete first after realizing that an incorrect dose of medication
has been administered to a patient? (Select all that apply.)
A) Documentation of the error
B) Notification of the physician
C) Notification of the patient and family
D) Preparation for a root cause analysis
ANSWER: A, B, C, D
Explanation: A) (Note: This requires multiple responses to be correct.) Although they are all correct, #2
should be completed first and a plan developed to ensure that the patient is not harmed. Nursing
Process: Evaluation
B) (Note: This requires multiple responses to be correct.) Although they are all correct, #2 should be
completed first and a plan developed to ensure that the patient is not harmed. Nursing Process:
Evaluation
C) (Note: This requires multiple responses to be correct.) Although they are all correct, #2 should be
Evaluation
D) (Note: This requires multiple responses to be correct.) Although they are all correct, #2 should be
Evaluation

9
9) The nurse working within the AACN Synergy Model realizes that optimal patient outcomes are realized when:
A) Highly qualified nurses care for patients in highly technical settings.
B) Nurses agree to work overtime to cover unit staffing needs.
C) Staff nurse competency is matched with patient needs.
D) Patient care is delivered within a "closed unit" model.
ANSWER: C
Explanation: A) #1, #2, and #4 are not correct. The underlying assumption of the synergy model is that
optimal patient outcomes occur when the needs of the patient and family are matched with the
competencies of the nurse.
Level: Application
B) #1, #2, and #4 are not correct. The underlying assumption of the synergy model is that optimal
patient outcomes occur when the needs of the patient and family are matched with the
Level: Application
C) #1, #2, and #4 are not correct. The underlying assumption of the synergy model is that optimal
Level: Application
D) #1, #2, and #4 are not correct. The underlying assumption of the synergy model is that optimal
Level: Application

10
10) The competent critical care nurse demonstrates an understanding of patient advocacy by taking which of the
following actions? (Select all that apply.)
A) Maintaining attendance at the bedside with the patient during a physician visit
B) Assisting and supporting the patient and family as they reveal their needs
C) Alerting the physician to concerns about patient placement after hospitalization
D) Encouraging and supporting a patient's spouse in preparing for a family meeting ANSWER:
A, B, C, D
#1, #2, #3, and #4 all indicate ways in which the new critical care nurse could demonstrate an
understanding of patient advocacy.
Level: Analysis
Category of Need: Psychosocial Integrity
Level: Analysis
#1, #2, #3, and #4 all indicate ways in which the new critical care nurse could
demonstrate an understanding of patient advocacy.
Level: Analysis
Level: Analysis

11
11) A nurse is preparing to communicate an issue about patient care to a physician using the SBAR technique.
Which of the following phrases is an appropriate initial statement?
A) "I am concerned about…"
B) "The patient's immediate history is…"
C) "I think the problem is…"
D) "I would like you to …"
ANSWER: A
Explanation: A) #2, #3, and #4 are statements pertinent to other portions of the SBAR. Nursing
Process: Evaluation
B) #2, #3, and #4 are statements pertinent to other portions of the SBAR. Nursing
Process: Evaluation
C) #2, #3, and #4 are statements pertinent to other portions of the SBAR. Nursing
Process: Evaluation
D) #2, #3, and #4 are statements pertinent to other portions of the SBAR. Nursing
Process: Evaluation
12) The nurse would include which statement for-"Assessment" in the SBAR technique for
communication?
A) "I think the problem is…"
B) The patient's vital signs are…"
C) "The patient's treatments are…"
D) "I would like you to…"
ANSWER: A
Explanation: A) #1 is correct. #2, #3, #4 are statements pertinent to other portions of the SBAR. Nursing
Process: Evaluation
B) #1 is correct. #2, #3, #4 are statements pertinent to other portions of the SBAR. Nursing
Process: Evaluation
C) #1 is correct. #2, #3, #4 are statements pertinent to other portions of the SBAR. Nursing
Process: Evaluation
D) #1 is correct. #2, #3, #4 are statements pertinent to other portions of the SBAR. Nursing
Process: Evaluation

12
13) To complete an SBAR communication about a patient issue, the nurse should use which of the following statements?
A) "The patient's immediate history is…"
B) "The patient's physical findings are…"
C) "I am requesting that you…"
D) "I have assessed the patient personally."
ANSWER: C
Explanation: A) #3 is correct. #1, #2, #4 are statements pertinent to other portions of the SBAR.
Nursing Process: Evaluation
B) #3 is correct. #1, #2, #4 are statements pertinent to other portions of the SBAR. Nursing
Process: Evaluation
C) #3 is correct. #1, #2, #4 are statements pertinent to other portions of the SBAR. Nursing
Process: Evaluation
D) #3 is correct. #1, #2, #4 are statements pertinent to other portions of the SBAR. Nursing
Process: Evaluation

13
14) Nurses must be able to collaborate with other members of the health care team in order to effect optimal outcomes in
patient care. The nurse understands that characteristics of emotional maturity within the profession include: (Select all
that apply.)
A) Being a lifelong learner.
B) Actively identifying best practices.
C) Maintaining current skills.
D) Overlooking one's own shortcomings.
ANSWER: A, B, C
#4 does not describe an attribute of emotional maturity in nursing. Nursing
Process: Assessment
Cognitive Level: Comprehension Category of
Need: Psychosocial Integrity
Process: Assessment
Process: Assessment
Process: Assessment

14
15) A nurse might utilize a variety of informal power bases in the health care setting. These include: (Select all that apply.)
A) Information.
B) Expertise.
C) Goodwill.
D) Observation.
ANSWER: A, B, C
Observation, although important, is not considered to be a form of power. Nursing
Process: Assessment
Process: Assessment
Process: Assessment
Process: Assessment

15
16) When a nurse encourages a patient who has experienced a motor vehicle crash to cough and
deep- breathe even the patient does not initially want to, the nurse is placing a priority on which of the following ethical
principles?
A) Beneficence
B) Nonmaleficence
C) Respect for persons
D) Justice
ANSWER: B
Explanation: A) According to ethicists, nonmaleficence should take precedence over beneficence because
it is more important to avoid doing harm to patients than to attempt to benefit them. Nursing
Process: Evaluation
B) According to ethicists, nonmaleficence should take precedence over beneficence because it is more
important to avoid doing harm to patients than to attempt to benefit them. Nursing Process:
Evaluation
C) According to ethicists, nonmaleficence should take precedence over beneficence because it is more
Evaluation
D) According to ethicists, nonmaleficence should take precedence over beneficence because it is more
Evaluation

16
17) When a nurse forcibly inserts a nasogastric tube against the patient's wishes, the nurse can be held l iable for:
A) Assault.
B) Battery.
C) Civil penalties.
D) Malpractice.
ANSWER: B
Explanation: A) When the nurse treats or touches a patient without consent, it is battery.
NursingProcess:Implementation Cognitive
Level: Application
B) When the nurse treats or touches a patient without consent, it is battery. Nursing
Process: Implementation
C) When the nurse treats or touches a patient without consent, it is battery. Nursing
D) When the nurse treats or touches a patient without consent, it is battery. Nursing

17
18) The nurse is aware that decisi-om
n aking capacity is likely to be impaired for patients who: (Select all that apply.)
A) Are depressed.
B) Are being medicated for severe pain.
C) Do not understand their medical condition.
D) Have been diagnosed with septic shock.
ANSWER: A, B, C, D
In each case, the patient is unable to meet at least one of the three components of informed
consent.
Level: Analysis
consent.
Level: Analysis
consent.
Level: Analysis
consent.
Level: Analysis

18
19) The nurse is aware that restraining a patient is most likely to result in the patient:
A) Pulling out an endotracheal tube.
B) Pulling out an intravenous line.
C) Disconnecting ventilator tubing.
D) Developing a nosocomial infection.
ANSWER: D
Explanation: A) #1, #2, and #3 are actions that nurses believe unrestrained patients may accomplish an
which may result in harm to the patients. Nursing
Process: Evaluation
B) #1, #2, and #3 are actions that nurses believe unrestrained patients may accomplish an which may
result in harm to the patients.
Level: Analysis
C) #1, #2, and #3 are actions that nurses believe unrestrained patients may accomplish an which may
Level: Analysis
D) #1, #2, and #3 are actions that nurses believe unrestrained patients may accomplish an which may
Level: Analysis

19
20)For a nurse to be found guilty of negligence, which of the following must be demonstrated? That the patient:
A) Was assaulted.
B) Was not consulted before being touched.
C) Suffered a wrongful death.
D) Incurred damages.
ANSWER: D
Explanation: A) In order to prove negligence, a duty must be owed; a duty must have been breached; the
breach of duty caused injury to the patient; and there were damages. Nursing
Process: Evaluation
Cognitive Level: Comprehension
B) In order to prove negligence, a duty must be owed; a duty must have been breached; the breach of
duty caused injury to the patient; and there were damages.
C) In order to prove negligence, a duty must be owed; a duty must have been breached; the breach of
D) In order to prove negligence, a duty must be owed; a duty must have been breached; the breach of

20
21) Moral distress among critical care nurses is associated with: (Select all that apply.)
A) Providing aggressive care to patients who cannot benefit.
B) Having no voice in clinical decision making.
C) Realizing that nurses maintain power in bedside decision making.
D) Knowing the right thing to do but not being able to do it.
ANSWER: A, B, D
#3 lacks accuracy according to nurses' reports in studies. Nursing
Process: Evaluation
Category of Need: Physiological Integrity–Basic Care and Comfort
Process: Evaluation
Process: Evaluation
Process: Evaluation

21
22) When a nurse employs conscientious refusal to participate, the nurse should be aware that: (Select all that apply.)
A) Consequences may involve employer sanction.
B) It may lead to dismissal from a nursing position.
C) Nursing administrators are largely supportive.
D) State boards of nursing protect the nurse in this situation.
ANSWER: A, B
Although some nursing administrators are supportive, this is not a widely held view (#3). #4 is
not universally true. Therefore, the nurse must be aware of the state nurse practice act.
Level: Analysis
Level: Analysis
Level: Analysis
Level: Analysis

22
23) Which of the following symptoms seen in a nurse would suggest compassion fatigue? (Select all that apply.)
A) Difficulty separating work from personal life
B) Excessive high tolerance for frustration
C) Having a completely laisse
- fzaire attitude
D) Decreased functioning in nonprofessional situations
ANSWER: A, D
#2 and #3 are opposing behaviors and are not indicative of compassion fatigue. Nursing
Process: Evaluation
Process: Evaluation
Process: Evaluation
Process: Evaluation

1
Perrin: Understanding the Essentials of Critical Care Nursing Chapter
2: Care of the Critically Ill Patient
MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the ques
1) "Resiliency" in the American Association of Crit-iC
c alr e Nurses synergy model refers to a person's:
A) Motivation to reduce anxiety through positive-steallfk.
B) Ability to bounce back quickly after an insult.
C) Physical strength to endure extreme physical stressors.
D) Ability to return to a state of equilibrium.
ANSWER: B
Explanation: A) The correct definition of "resiliency" is the ability to bounce back quickly after an insult.
The degree of resiliency is placed along a continuum between being unable to mount a response to
having strong reserves. Other characteristics of this model include: vulnerability, stability, complexity,
predictability, resource availability, participation in care, and participation in decision making. #1 and
#3 do not define resiliency and are no related to the synergy model patient characteristics. #4,
"stability," is defined as the ability to return to a state of equilibrium and range between
unresponsive to therapies and at high risk for death to stable and responsive to therapy.
Nursing Process: Planning Cognitive
B) The correct definition of "resiliency" is the ability to bounce back quickly after an insult. The degree
of resiliency is placed along a continuum between being unable to mount a response to having strong
reserves. Other characteristics of this model include: vulnerability, stability, complexity, predictability,
resource availability, participation in care, and participation in decision making. #1 and #3 do not
define resiliency and are no related to the synergy model patient characteristics. #4, "stability," is
defined as the ability to return to a state of equilibrium and range between unresponsive to therapies
and at high risk for death to stable and responsive to therapy.
C) The correct definition of "resiliency" is the ability to bounce back quickly after an insult. The degree
of resiliency is placed along a continuum between being unable to mount a response to having strong
reserves. Other characteristics of this model include: vulnerability, stability, complexity, predictability,
resource availability, participation in care, and participation in decision making. #1 and #3 do not
define resiliency and are no related to the synergy model patient characteristics. #4, "stability," is
defined as the ability to return to a state of equilibrium and range between unresponsive to therapies
and at high risk for death to stable and responsive to therapy.

2
D) The correct definition of "resiliency" is the ability to bounce back quickly after an insult. The degree
of resiliency is placed along a continuum between being unable to mount a response to having
strong reserves. Other characteristics of this model include: vulnerability, stability, complexity,
predictability, resource availability, participation in care, and participation in decision making. #1 and
#3 do not define resiliency and are no related to the synergy model patient characteristics. #4,
"stability," is defined as the ability to return to a state of equilibrium and range between unresponsiv
e to therapies and at high risk for death to stable and responsive to therapy.
2) Which of the following is the AACN's synergy model patient characteristic described as "the intricate
entanglement of two or more systems"?
A) Complexity
B) Predictability
C) Participation in care
D) Resource availability
ANSWER: A
Explanation: A) #2, #3, and #4 are other terms used in the synergy model.
B) #2, #3, and #4 are other terms used in the synergy model.
Nursing Process: Planning
C) #2, #3, and #4 are other terms used in the synergy model.
D) #2, #3, and #4 are other terms used in the synergy model.
3) Which of the following stressors is one of the primary concerns of critically ill patients and should therefore
be included routinely in patient assessments?
A) Inability to control elimination
B) Lack of family support
C) Hunger
D) Altered ability to communicate
ANSWER:D

3
Explanation: A) Other items included in Cornock's categories are: being thirsty, having tubes in the mouth and nose,
being restricted by tubes/lines, being unable to sleep, and not being able to control themselves. #1,
#2, and #3 are incorrect. Although the inability to contro elimination is similar to not being able to
control one's self, the interpretation by Cornoc does not include this aspect as a stressor. Lack of
family support and hunger were not identified as stressors by his research.
Nursing Process: Assessment Cognitive
Level: Application
B) Other items included in Cornock's categories are: being thirsty, having tubes in the mouth and nose,
Level: Application
C) Other items included in Cornock's categories are: being thirsty, having tubes in the mouth and nose,
Level: Application
D) Other items included in Cornock's categories are: being thirsty, having tubes in the mouth and nose,
Level: Application
4) A patient has just completed a preoperative education session prior to undergoing coronary artery bypass surgery.
Which statement by the patient would indicate that he needs additional teaching by the nurse? (Select all that apply.)
A) "I understand that I will have to blink my eyes to respond after the breathing tube is in my throat."
B) "I will be given frequent mouth care to help me when I am thirsty."
C) "I will be able to move about freely in bed and into the chair without help while connected to the electronic
equipment for monitoring."
D) "I may need something to help me rest due to the unfamiliar lights and sounds of the ICU unit." ANSWER:
A, B, D

4
The question is asking for the response that reflects inaccurate information. #3 reflects that the
patient did not understand the physical limitations and the need for assistance when moving and
getting in and out of bed. #1, #2, and #4 are correct understanding of the limitation required by the
patient in ICU. Alternate method of communication discussed in advance of tube placement will
assist in better communication after the tub is inserted to assist the breathing process. While
intubated, oral hygiene is needed to prevent mucosal drying due to the inability of the patient to
drink. Due to environmental lights, sounds, and difference in sleeping environment, additional aids,
such as drug management, may be needed to assist the patient to rest at night.
Level: Analysis
Level: Analysis
Level: Analysis
Level: Analysis

5
5) When providing care to critically ill patients, whether they are responsive or unresponsive, the nurse should:
A) Clearly explain what care is to be done before starting the activity.
B) Perform the activity then let the patient rest without explaining the care.
C) Make sure the patient always responds and is cooperative before giving care.
D) Explain to the family that the patient will not understand or remember any of the discomfort associated
with care.
ANSWER: A
Explanation: A) By explaining to both the responsive and unresponsive patient, the nurse provides orientation,
reassurance, respect, and assessment of the patient's mental status. Seeking permission and
apologizing if discomfort is involved will also minimize the stress of the critically ill patient by
hearing what is about to occur. Even the unresponsive patient has been known to explain
procedures, conversations, and feelings once they have awakened. #2 is incorrect. If the patient is
not informed, autonomy and the right to choose have been violated; in addition the stress of the
unknown may be perceived incorrectly by the patient as an assault. #3 is incorrect. Some
unresponsive patients will never respond; therefore, the care would not be performed as needed.
Cooperation is also not possible in some cases whereby the patient has altered thinking. Although
the nurse desires these, the care should not be stopped just because they cannot be obtained
Explaining should still be done and the care should proceed as needed. #4 is incorrect: The nurse
cannot always reassure the family that the patient will not remember.
Nursing Process: Implementation Cognitive
Level: Application
B) By explaining to both the responsive and unresponsive patient, the nurse provides orientation,
cannot always reassure the family that the patient will not remember. NursingProcess:
Implementation

6
C) By explaining to both the responsive and unresponsive patient, the nurse provides orientation,
cannot always reassure the family that the patient will not remember. NursingProcess:
Implementation
D) By explaining to both the responsive and unresponsive patient, the nurse provides orientation,
cannot always reassure the family that the patient will not remember.
Level: Application
6) Which of the following communication strategies is most appropriate for a critical care nurse to use when
communicating with a ventilated patient? The nurse should:
A) Use professional terminology and provide the patient with detailed information.
B) Use simple language and explain in other terms if the patient does not seem to understand.
C) Provide minimal information so the patient is not overwhelmed.
D) Discuss issues primarily with the family because the patient is unlikely to understand the information.
ANSWER: B

7
Explanation: A) Simple layman's language of information is better understood and by repeating or rephrasing the
patient gains a better understanding when in a stressful situation. #1 is incorrect. Individuals who
are not familiar with health care often do not understand professional language. Confusion and a
lack of understanding often result if the information is presented only in professional terminology.
#3 is incorrect. Minimal disclosure of information will increase the stress of the patient by
increasing confusion and concerns from the lack of understanding about the illness or treatment
process.
Complete disclosure is the right of the patient and the obligation of health care professionals. #4 is
incorrect. Disclosing information or communicating only with the patient's family denies the patient
the right of choice and the respect or dignity expected Legally and ethically, except under very
specific restrictions, the patient has a right to know, and it is the health care professionals'
responsibility to explain clearly for informed consent to occur.
NursingProcess:Implementation
B) Simple layman's language of information is better understood and by repeating or rephrasing the
process. Complete disclosure is the right of the patient and the obligation of health care
professionals. #4 is incorrect. Disclosing information or communicating only with the patient's
family denies the patient the right of choice and the respect or dignity expected Legally and
ethically, except under very specific restrictions, the patient has a right to know, and it is the health
care professionals' responsibility to explain clearly for informed consent to occur.
NursingProcess: Implementation
C) Simple layman's language of information is better understood and by repeating or rephrasing the
family denies the patient the right of choice and the respect or dignity expected Legally and
ethically, except under very specific restrictions, the patient has a right to know, and it is the health
care professionals' responsibility to explain clearly for informed consent to occur.
NursingProcess:Implementation

8
D) Simple layman's language of information is better understood and by repeating or rephrasing the
family denies the patient the right of choice and the respect or dignity expected Legally and ethically,
except under very specific restrictions, the patient has a right to know, and it is the health care
professionals' responsibility to explain clearly for informed consent to occur.
Level: Application
7) During an assessment, a ventilated patient begins to frown and wiggle about in bed. Which assessment strategy
would be most helpful for the nurse to validate these observations?
A) Glasgow Scale
B) Maslow's hierarchy levels
C) Critica-l Care Pain Observation Tool (CPOT)
D) Vital signs trends
ANSWER: C
Explanation: A) The CPOT pain scale will identify if pain is present and the degree of effectiveness of
drug management in a patient who cannot speak due to intubation. Incorrect responses are #1,
#2, and #4. The Glasgow Coma Scale will identify the level of consciousness present to evaluate
the sedation level that is used with patients who are intubated. But this scale does not identify the
source of the problem that has increased the patient's facial changes or movement. Maslow's
hierarchy of needs prioritizes the needs based on essential to higher level functions in the body,
and it would not help identify the source of the changes noted in the patient. Vital signs might tell
the nurse that a change has occurred but it does not indicate the source of the discomfort or
problem.
Level: Application
Category of Needs: Physiological Integrity–Reduction of Risk Potential
B) The CPOT pain scale will identify if pain is present and the degree of effectiveness of drug
management in a patient who cannot speak due to intubation. Incorrect responses are #1, #2, and
#4. The Glasgow Coma Scale will identify the level of consciousness present to evaluate the
sedation level that is used with patients who are intubated. But this scale does not identify the
problem.
Level: Application

9
C) The CPOT pain scale will identify if pain is present and the degree of effectiveness of drug
problem.
Level: Application
D) The CPOT pain scale will identify if pain is present and the degree of effectiveness of drug
problem.
Level: Application
8) Nurses in many ICUs are required to automatically attempt to wean sedation for their ventilated patients when the
patients meet certain parameters. Which of the following parameters would indicate that a patient in ICU is ready for
such an interruption in sedation, also sometimes known as a sedation vacation? The patient: (Select all that apply.)
A) Activated the ventilator alarms but the alarms stopped spontaneously.
B) Frowned when turned but otherwise showed no muscular tension.
C) Had a MAP of 75 and heart rate of 76.
D) Was sleeping but awakened with verbal stimuli.
ANSWER: A, B, C, D
#1, #2, #3, and #4 are correct. Daily weaning of sedatives should automatically be attempted
when the patient meets the following criteria:
™ VAMASS is less than or equal to target VAMASS.
™ Sedation is not being used to treat delirium.
™ Patient is not receiving neuromuscular blocking agents.
™ Patient is hemodynamically stable.
™ Patient is stable on the ventilator.
™ Patient's pain is controlled.

10
9) A patient scores positive on the Confusion Assessment Method of the Intensive Care Uni-tI(
C
C
U
A)
M
.
Which of the following nursing diagnoses would have the highest priority based on this positive score?
A) Injury, Risk for
B) Family Processes, Altered
C) Social Interaction, Impaired
D) MemoryImpaired
ANSWER:A

11
Explanation: A) Injury falls into the Safety/Security level, which is the highest priority. #2 and #3 are incorrect.
Social interactions fall in the Love/Belonging category, which is in the next highest level. #4 is
incorrect. Mental impairment falls in t h
- e sS
t ee
l fm level, which is the next highest level. (Note: No
example of the-S
ac
et
lf
ualization level was given and is the highest level of need according to
Maslow's theory)
Level: Analysis
B) Injury falls into the Safety/Security level, which is the highest priority. #2 and #3 are incorrect.
- e sS
t ee
example of the-S
ac
et
lf
Maslow's theory)
Level: Analysis
C) Injury falls into the Safety/Security level, which is the highest priority. #2 and #3 are incorrect.
- e sS
t ee
example of the-S
ac
et
lf
Maslow's theory)
Level: Analysis
D) Injury falls into the Safety/Security level, which is the highest priority. #2 and #3 are incorrect.
- e sS
t ee
example of the-S
ac
et
lf
Maslow's theory)
Level: Analysis
10) A nurse is beginning an intravenous infusion of morphine sulfate on her
- o
pp
os
vtentilated patient.
When initiating the infusion and for the first few hours, the nurse should do which of the following?
A) Anticipate that the patient will begin to experience the effect of the morphine 5 minutes after the start of the
infusion.
B) Begin the infusion at the lowest ordered dose and increase the rate every 5 minutes if the patient continues to
have pain.
C) Complete the Critic-aC
l are Pain Observation Tool scale 5 minutes after increasing the infusion rate each time.
D) Provide additional intermittent boluses of morphine sulfate if the patient experiences breakthrough pain.
ANSWER: D

12
Explanation: A) Intravenous (IV) infusions of analgesics, such as the commonly used medication morphine sulfate,
start to act immediately; however, they will not provide significant analgesia until the infusion
reaches "steady state." At the initiation of an infusion and when the infusion rate is increased,
loading doses must be administered in order to provide immediate analgesia and maintain the
desired analgesia until the infusion reaches steady state. Thus, a critically ill patient often will
receive an IV bolus of an analgesic followed by an ongoing infusion of the pain medication with
intermittent boluses and increases in infusion until the drug attains steady state and the patient
experiences pain relief. In response to anticipated painful procedures (e.g., turning) the patient
might receive an additional bolus. When IV infusion rates are repeatedly increased versus the
administration of intermittent boluses as a means of responding to acute pain, the risk for excessive
analgesia dosing exists.
Cognitive Level: Application Nursing
Process: Evaluation
B) Intravenous (IV) infusions of analgesics, such as the commonly used medication morphine sulfate,
Process: Evaluation
C) Intravenous (IV) infusions of analgesics, such as the commonly used medication morphine sulfate,
Process: Evaluation

13
D) Intravenous (IV) infusions of analgesics, such as the commonly used medication morphine sulfate,
Process: Evaluation
11) Which of the following strategies should the nurse include in the plan of care when trying to minimize sleep
disruptions for a patient in an ICU? (Select all that apply.)
A) Instituting a short course of therapy for sleeping agents
B) Accurate scoring and vigilance in sedation and sedation scoring
C) Managing the environment to reduce lighting, sounds, and so on
D) Minimizing staff interruptions during sleep periods
E) Scheduling treatments only during the day or at least 4 hours apart at night
ANSWER: A, B, C, D
#1, #2, #3, and #4 are all correct strategies to minimize interruptions of sleep and to maximize the
rest benefits that will shorten the duration of care based on research findings. #5 is incorrect.
Planning the care for only the day hours or at least 4 hours is not practical to improve the outcomes
of the client, because some medications, therapies and assessments need to be made around the
clock for the greatest benefits to patients. The minimum time for resting that is suggested is to not
interrupt less than 2 hours of sleep in order to minimize sleep fragmentation and improve restful
sleep.
Level: Analysis
sleep.
Level: Analysis

14
sleep.
Level: Analysis
sleep.
Level: Analysis
E) (Note: This requires multiple responses to be correct.)
interrupt less than 2 hours of sleep in order to minimize sleep fragmentation and improve restful sle
ep.
Level: Analysis
12) A nurse is confirming the medication orders and schedule for sedative administration to a patient with delirium.
Which of the following schedules would maximize the effectiveness of the drugs? Administration of medication:
A) Only in the early morning.
B) Only at bedtime (HS).
C) Around the clock with higher dosages in the evening.
D) Only on an as
- needed (PRN) basis.
ANSWER: C
Explanation: A) Timing given around the clock with a greater dosage in the evening will match the
symptom of undowning when the symptoms appear the greatest later in the day. #1, #2, and #4
are incorrect. Timing would not reflect the symptoms nor control the condition equally throughout
the 2
-4
hour period. Additional dosages besides the dosage around the clock can be given on a PRN
basis when acute exacerbations occur.
Level: Analysis

15
B) Timing given around the clock with a greater dosage in the evening will match the symptom of
undowning when the symptoms appear the greatest later in the day. #1, #2, and #4 are incorrect.
Timing would not reflect the symptoms nor control the condition equally throughout the 2
-4
hour
period. Additional dosages besides the dosage around the clock can be given on a PRN basis when
acute exacerbations occur.
Level: Analysis
C) Timing given around the clock with a greater dosage in the evening will match the symptom of
-4
hour
Level: Analysis
D) Timing given around the clock with a greater dosage in the evening will match the symptom of
-4
hour
Level: Analysis
13) Which of the following patients would be considered at risk for nutritional imbalances? A patient: (Select all that apply.)
A) Who is a stable po-stMI.
B) With renal dysfunctions/failure.
C) With slightly elevated liver enzymes.
D) With burns or excessive trauma.
E) Who is intubated and sedated.
ANSWER: A, B, D, E
All of these patients need additional calories, alterations in types of nutrition given, or an alternate
form of nutritional delivery to maintain or achieve nutritional balance based on physiological needs
for each condition. #3 is incorrect. Although the liver does filter drugs and alter the breakdown of
drugs, nutrition is rarely modified just for slightly elevated liver enzymes. Severe liver damage or
failure will result in restrictions of alcohol and fatty foods, and an increase protein may be needed.
Level: Analysis
Category of Need: Physiological Integrity–Reduction of Risk Potential

16
Level: Analysis
Level: Analysis
Level: Analysis
E) (Note: This requires multiple responses to be correct.)
Level: Analysis
14) While members of the multidisciplinary team are reviewing a patient's nutritional status, they note the following
values. Which of the values would need additional investigation?
A) A serum albumin of more than 3.5 g/dL or 35 g/L
B) A weight increase of 1.5 kg in a day
C) A serum hemoglobin of 11.7 g/dL or 117 mmol/L
D) A serum magnesium of 1.6 mg/dL or 132 mEq/L
ANSWER: B

17
Explanation: A) A weight change of 1.5 kg (approximately 3.3 lb) reflects approximately 1.5 liters of fluid Additional
assessment needs to be done to evaluate the cause and risks. #1, #3, and #4 are incorrect. These
lab values are at the lower end of the normal levels for adults and d not require additional
assessment or interventions. However, if the albumin drops below
3.5 g/dL, then the declining lab may reflect changes in the protein status of the body tha should be
further assessed.
Level: Analysis
B) A weight change of 1.5 kg (approximately 3.3 lb) reflects approximately 1.5 liters of fluid Additional
further assessed.
Level: Analysis
C) A weight change of 1.5 kg (approximately 3.3 lb) reflects approximately 1.5 liters of fluid Additional
further assessed.
Level: Analysis
D) A weight change of 1.5 kg (approximately 3.3 lb) reflects approximately 1.5 liters of fluid Additional
further assessed.
Level: Analysis

18
15) A nurse has inserted a nasogastric tube and is planning to confirm placement of the tube prior to starting enteral
feedings. Which of the following is the most accurate method for confirming placement? By:
A) Obtaining a radiological-x
r ay of the abdomen.
B) Checking gastric aspirate for a pH of less than 7.
C) Instilling 30 mL of air while listening with a stethoscope when placed over the fundus of the stomach.
D) Determining the presence of carbon dioxide.
ANSWER: A
Explanation: A) It is the gold standard for determining placement of the tube. #4 is an incorrect
assessment to validate placement. #2 and #3 might be procedures used to validate placement;
however, the pH in #2 is too high and air auscultation has been shown to be inaccurate.
Level: Application
B) It is the gold standard for determining placement of the tube. #4 is an incorrect assessment to
validate placement. #2 and #3 might be procedures used to validate placement; however, the pH
in #2 is too high and air auscultation has been shown to be inaccurate.
Level: Application
C) It is the gold standard for determining placement of the tube. #4 is an incorrect assessment to
Level: Application
D) It is the gold standard for determining placement of the tube. #4 is an incorrect assessment to
Level: Application
16) Which of the following nursing diagnoses should receive the highest priority when caring for a patient who is
receiving total parenteral nutrition?
A) Infection, Risk for
B) Trauma, Risk for
C) Skin Integrity, Impaired
D) Fluid Volume, Risk for Imbalance
ANSWER:A

19
Explanation: A) #1 is the greatest risk for the parenteral nutrition patient due to the high glucose presen the central
vein access route, and the declining nutritional status that the patient is in when this therapy is
started. Absolute sterility, close assessment of glucose balances that are maintained by additional
insulin treatment, and the need to maximize nutritional intake for healing to occur will minimize the
risk of infection. #2, #3, and #4 are still important in the planning process for the care to this
patient, but the infection risk can be deadly to this patient. Avoiding trauma at the site or other
parts of the body should be routinely done to "do no harm" and avoid injury where possible. Skin
integrity will be impaired due to poor nutritional intake, but preventive measures can be done to
decrease the risk. Fluid volume imbalances are minimized by accurate regulators to limit fluid
overload or to run at the appropriate rate to provide the essential nutrition needed. Standards of care
for pump regulation minimize both the fluid overload and fluid deficits that might occur if solutions
were freely hung to be regulated by drop methods. Nursing Process: Evaluation
Category of Need: Physiological Integrity–Physiological Adaptations
B) #1 is the greatest risk for the parenteral nutrition patient due to the high glucose presen the central
overload or to run at the appropriate rate to provide the essential nutrition needed. Standards of
care for pump regulation minimize both the fluid overload and fluid deficits that might occur if
solutions were freely hung to be regulated by drop methods. Nursing Process: Evaluation
C) #1 is the greatest risk for the parenteral nutrition patient due to the high glucose presen the central

20
D) #1 is the greatest risk for the parenteral nutrition patient due to the high glucose presen the central
17) When planning care to meet the needs of family members of a critically ill patient, the nurse should include:
(Select all that apply.)
A) Expressing an attitude of hope, honesty, open communication, and caring.
B) Stating specific facts about the patient's condition in timely manner.
C) Planning regular times for family visits throughout the day.
D) Limiting the number of visitors to significant others.
E) Communicating to a single family member to cut down time wasted repeating information to all visitors.
ANSWER: A, B, C
#1, #2, #3 are appropriate approaches when meeting the family needs of the critically il patient. An
open access by the significant others of the patient has been validated by research to improve
medical outcomes. A sense of concern for the patient will reduce stress within the family, and clear
simple explanations will maximize the communication process to a stressed family member. #4:
Although some number limitations are needed, the persons are not to be screened by staff. If the
patient wants the visitor to come in, then the visit will be therapeutic for the patient. If the visitor
(family or friend) increases problems with the patient, then the visitor should be restricted access
until the condition improves. #5: Although communicating with a single person will minimize the
repeating of information, a core group of individuals can be used to distribute information to other
family members, particularly if a large population is present. Therefore, restricting to one person is
too limiting but a minimal core group can be helpful in other situations, especially if the nurse is
needed at the bedside. A case manager, clergy, or staff support person could also be used to pass on
information when the nursing staff is too busy caring for the patient.
Nursing Process: Implementation Cognitive
Level: Application

21
Level: Application
Level: Application

TEST BANK For Understanding the Essentials of Critical Care Nursing, 3rd Edition by Perrin.pdf

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