NUR 425 Exam 1 Practice Questions and
Solutions
Which of the following is true about sedating patient in the ICU?
1. Patients in the Icu must be sedated
2. Most patients who are intubated are sedated
3. All sedative medications provide pain relief
4. Sedated patients require less monitoring ✅2. Most patients who are intubated are
sedated
Not everyone is sedated in the ICU, this is done mostly for patient comfort, to facilitate
interventions, reduce anxiety/fear/agitation and other reasons. While some pain
medications may be used for sedation, not all sedation provides pain relief (Midazolam,
Propofol)
Which of the following BEST describes delirium?
1. Long term memory loss
2. Anger
3. Chronic hallucinations
4. Inability to focus ✅4. Inability to focus
Inattention is the number one sign of delirium -- short term memory loss, restlessness,
acute confusion are also notable -- delirium is an acute problem, not chronic
What isa nurse allowed to do once a patient is on propofol drip for sedation?
1. Administer boluses for acute agitation
2. Increase the drip rate
3. Change to Midazolam if it's ineffective
4. Make minor changes to the protocol ✅2. Increase the drip rate
The nurse can increase the drip rate per protocol -- boluses are not within our scope of
practice. Changes cannot be made to the protocol and medication changes must be
order by the physician
Which of the following patient most likely needs to be sedated?
1. A 24 year old male reporting 9/10 pain admitted after a motor vehicle accident with a
fractured right humerus
, 2. A 45 year old female admitted status post gunshot wound to the abdomen. She has
just undergone abdominal surgery and is coming to the ICU on a ventilator
3. A 64 year old male admitted to the ICU with atrial fibrillation and a large deep vein
thrombosis in his right femoral vein ✅2. A 45 year old female admitted status post
gunshot wound to the abdomen. She has just undergone abdominal surgery and is
coming to the ICU on a ventilator
Which of the following are appropriate for assessing pain in a nonverbal patient? (select
all that apply)
1. assess facial expression
2. assess temperature
3. assess changes in heart rate
4. assess resistance to passive movement of the arms ✅1. assess facial expression
3. assess changes in heart rate
4. assess resistance to passive movement of the arms
Which of the following would be an appropriate intervention by the nurse to reduce pain
for a nonverbal patient who is fidgeting in bed?
1. change medication order from tylenol to fentanyl drip
2. increases the fentanyl drip per protocol and have a family member help you play
music from the patient's cell phone
3. increase the patient's propofol drip rate within the parameters listed on the protocol
4. decrease the patient's propofol drip rate within the parameters listed on the protocol
✅2. increases the fentanyl drip per protocol and have a family member help you play
music from the patient's cell phone
Which of the following is an appropriate scale to assess level of sedation in an ICU
patient?
1. Ramsay sedation scale
2. ICUOPT Sedation scale
3. COPT scale
4. wong baker sedation scale ✅1. Ramsay sedation scale
Which of the following is NOT an appropriate nursing role in the sedated patient?
1. monitor patient's vital signs in response to sedative medication
2. monitor patient's level of sedation according to hospital protocol
Solutions
Which of the following is true about sedating patient in the ICU?
1. Patients in the Icu must be sedated
2. Most patients who are intubated are sedated
3. All sedative medications provide pain relief
4. Sedated patients require less monitoring ✅2. Most patients who are intubated are
sedated
Not everyone is sedated in the ICU, this is done mostly for patient comfort, to facilitate
interventions, reduce anxiety/fear/agitation and other reasons. While some pain
medications may be used for sedation, not all sedation provides pain relief (Midazolam,
Propofol)
Which of the following BEST describes delirium?
1. Long term memory loss
2. Anger
3. Chronic hallucinations
4. Inability to focus ✅4. Inability to focus
Inattention is the number one sign of delirium -- short term memory loss, restlessness,
acute confusion are also notable -- delirium is an acute problem, not chronic
What isa nurse allowed to do once a patient is on propofol drip for sedation?
1. Administer boluses for acute agitation
2. Increase the drip rate
3. Change to Midazolam if it's ineffective
4. Make minor changes to the protocol ✅2. Increase the drip rate
The nurse can increase the drip rate per protocol -- boluses are not within our scope of
practice. Changes cannot be made to the protocol and medication changes must be
order by the physician
Which of the following patient most likely needs to be sedated?
1. A 24 year old male reporting 9/10 pain admitted after a motor vehicle accident with a
fractured right humerus
, 2. A 45 year old female admitted status post gunshot wound to the abdomen. She has
just undergone abdominal surgery and is coming to the ICU on a ventilator
3. A 64 year old male admitted to the ICU with atrial fibrillation and a large deep vein
thrombosis in his right femoral vein ✅2. A 45 year old female admitted status post
gunshot wound to the abdomen. She has just undergone abdominal surgery and is
coming to the ICU on a ventilator
Which of the following are appropriate for assessing pain in a nonverbal patient? (select
all that apply)
1. assess facial expression
2. assess temperature
3. assess changes in heart rate
4. assess resistance to passive movement of the arms ✅1. assess facial expression
3. assess changes in heart rate
4. assess resistance to passive movement of the arms
Which of the following would be an appropriate intervention by the nurse to reduce pain
for a nonverbal patient who is fidgeting in bed?
1. change medication order from tylenol to fentanyl drip
2. increases the fentanyl drip per protocol and have a family member help you play
music from the patient's cell phone
3. increase the patient's propofol drip rate within the parameters listed on the protocol
4. decrease the patient's propofol drip rate within the parameters listed on the protocol
✅2. increases the fentanyl drip per protocol and have a family member help you play
music from the patient's cell phone
Which of the following is an appropriate scale to assess level of sedation in an ICU
patient?
1. Ramsay sedation scale
2. ICUOPT Sedation scale
3. COPT scale
4. wong baker sedation scale ✅1. Ramsay sedation scale
Which of the following is NOT an appropriate nursing role in the sedated patient?
1. monitor patient's vital signs in response to sedative medication
2. monitor patient's level of sedation according to hospital protocol
