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AACN Essentials of Critical Care Nursing Correct answers
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AACN Essentials of Critical Care Nursing Correct answers
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Solution 2024/2025Pepper
AACN Essentials of Critical Care Nursing
Immediate Assessment ANS✔✔ A - airway
B - breathing
C - circulation, cerebral perfusion, chief complaint
D - drugs and diagnostic tests
E - equipment
Patient Safety Considerations ANS✔✔ Risk for pressure injury
Delirium
Infection
Falls
Airway ANS✔✔ Patency - Having the patient speak, watching the patient's chest rise and fall, or both
Position of artificial airway (if present)
ET tubes ANS✔✔ Endotracheal tube
, Solution 2024/2025
Pepper
Note the size and position of the airway
Note the marking closest to the teeth, lips, or nares to assist with future comparisons for proper placement
Suction the upper airway, either through the oral cavity or artificial airway to ensure that the airway is free from
secretions
Observe and document the amount, color, and consistency of any secretions removed
Breathing ANS✔✔ Quantity and quality of respirations (rate, depth, pattern, symmetry, effort, use of accessory muscles)
Breath sounds
Presence of spontaneous breathing
Observation of rate, depth, pattern, and symmetry of breathing
The effort of breathing
Use of accessory muscles
Breathing synchrony with the ventilator
Circulation and Cerebral Perfusion ANS✔✔ ECG
Rate, rhythm, and presence of ectopy
Blood pressure
Peripheral pulses and capillary refill
Skin, color, temperature, moisture
Presence of bleeding
Level of consciousness, responsiveness
Quickly palpating a pulse and viewing ECG
Color, temperature, and moisture of the skin, capillary refill
Chief Complaint ANS✔✔ Primary body system
Associated symptoms
Drugs and Diagnostic Tests ANS✔✔ Drugs prior to admission (prescribed, otc, illicit)
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