Exam 1 critical care 1. When planning care for a client who is critically ill, what action should the nurse implement to decrease the client's stress? a. Strictly limit visitors. b. Play soft soothing music. c. Set lighting for day/night cycles. *d .Plan care to minimize interactions with the clien...
when planning care for a client who is critically ill
what action should the nurse implement to decrease the clients stress
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Chamberlain College Of Nursing
NURSING 324 Exam 1 Critical Care (NURSING324)
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Exam 1 critical care
1. When planning care for a client who is critically ill, what action should the nurse implement to
decrease the client's stress?
a. Strictly limit visitors.
b. Play soft soothing music.
c. Set lighting for day/night cycles.
*d .Plan care to minimize interactions with the client.
2. The nurse is caring for a client with terminal cancer. It is essential for the nurse to consider which
aspect of this client's care?
a. Requesting that the chaplain visit the client.
*b. Compliance with the client's living will.
c. Maintaining a soothing environment.
d. Frequent family visitation.
3. When caring for an older adult client in the critical care setting, how can the nurse best assess for
pain?
a. Use the FACES Pain Scale.
*b. Observe non-verbal cues.
c. Use the visual analog scale.
d. Ask the client for a pain score.
4. . What finding would the nurse address first following the administration of an opioid analgesic in a
client who is critically ill?
a. Hypotension
b. Constipation
c. Increased pain
*d. Respiratory depression
TYPE: MA
5. In caring for a terminally ill client during the ventilator weaning process, the nurse should be alert
for which signs of discomfort? (Select all that apply)
*a. Dyspnea
*b. Tachycardia
c. Bradycardia
d. Hypotension
*e. Use of accessory muscles
6. When caring for a client in the critical care setting, which environmental factor should the nurse control
to reduce stress?
*a. Noise
b. Light
c. Visitation
d. Lack of privacy
7. An intensive care nurse is receiving bedside report from members of the healthcare team for further
management of care. What information would require immediate action by the oncoming team?
a. Wheezes are noted throughout lung fields on auscultation.
*b. There is noted paradoxical thoracoabdominal movement.
c. Client is on a ventilator that includes the use of heliox.
d. Client has a prolonged exhalation.
8. A client reporting dyspnea and chest pain with inhalation is being prepared for a high-resolution
multidetector computed tomography angiography (MCDTA). What information would the nurse include in
the plan of care?
,*a. The client should remain still during the diagnostic test
b. This is a nonspecific test, which could be positive with infections also
c. The client will have to have their legs available for the diagnostic test
d. This is an invasive test; afterwards the client will have to lie still for 4 hour
9. . What does the nurse understand has the most potential to be a risk factor for acute respiratory
distress syndrome in a client undergoing general anesthesia for surgery?
a. Poor nutritional stasis
*b. Aspiration of gastric contents
c. Pregnancy
d. Chronic bronchitis
10. A client is receiving corticosteroids for the development of acute respiratory distress syndrome
(ARDS). What would the nurse evaluate to determine the client is not developing side effects?
a. Monitor for lower extremity edema
b. Check skin turgor
*c. Assess the client’s mouth for thrush
d. Watch sclera for yellowing
11. A nurse is evaluating a post-operative client with chronic obstructive pulmonary disease for surgical
complications. What assessment finding would the nurse understand as a potential risk factor for the
development of post-surgical acute respiratory distress syndrome to be for this client?
*a. client is not orientated to person, place, or situation
b. client’s last food prior to surgery was ten hours ago
c. client states “sitting upright helps my breathing”
d. Clubbing of the fingers
12. The nurse is caring for a client with acute respiratory distress syndrome (ARDS) and is on mechanical
ventilation. What is the primary reason the client is being mechanically ventilated?
a. So the client is fed via nasogastric tube.
b. So the client can be sedated and rest.
c. To maintain adequate blood pressure.
*d. To manage the client’s respirations.
13. . A client with acute respiratory distress syndrome (ARDS) on mechanical ventilation is becoming
increasingly restless. The client’s heart rate is 128 beats/min and oxygen saturation is 88% on FiO2 of
50%. Coarse rhonchi are audible in all lung fields on auscultation. What action should the nurse
implement?
*a. Hyperoxygenate with 100% oxygen and suction the client.
b. Administer neuromuscular blockade as ordered.
c. Increase PEEP to 10 and sedate the client.
d. Increase FiO2 to 60% for five minutes.
, 14. . A nurse is analyzing a client’s lab values. What would the nurse understand factors into the analysis
of oxygen saturation levels of a client?
a. D-dimer assay
b. Glomerular filtration rate
c. Percentage of neutrophils
*d. Hemoglobin level
15. The nurse is caring for a client with a history of asthma who recently had surgery. The nurse is
suspecting possible acute respiratory failure. The client’s respiratory rate is 32 bpm and Sa02 is 88% on
room air. The client is reporting pain at a level of 3 out of 10. Which action is a priority?
*a. Apply oxygen device
b. Position client upright.
c. Provide pain medication as needed.
d. Prepare for lab draw for hemoglobin level.
16. A geriatric client is seen in the clinic with a diagnosis of chronic obstructive pulmonary disease
(COPD). What assessment information does the nurse understand could affect oxygenation and would be
a risk factor for the development for acute respiratory failure?
a. Presence of a barrel chest in the client
*b. Kyphosis
c. Hemoglobin of 10.1 mg/dL
d. Weight loss of 5 lbs in 6 months
17. A client presents to the Emergency Department (ED) with shortness of breath and use of accessory
muscles. Vital signs on admission are as follows: blood pressure of 130/88, heart rate of 102, respiratory
rate of 30, oxygen sat 89%. Which assessment findings are early indications of worsening respiratory
failure?
a. Subcutaneous crepitus, absent breath sounds, confusion
b. Dyspnea, circumoral cyanosis, distal cyanosis
c. Rales, distended neck veins, hypotension
*d. Restlessness, confusion, tachypnea
18. Which assessment finding is consistent with this condition?
a. Subcutaneous crepitus, absent breath sounds, confusion
b. Dyspnea, circumoral cyanosis, distal cyanosis
c. Rales, jugular venous distention, hypotension
*d. Agitation, disorientation, lethargy
19. Which response by the nurse demonstrates an understanding of the potential outcomes for a client
with respiratory failure and cardiogenic shock?
a. “The survival rate of clients with these conditions is high."
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