NUR 425 CC Exam 1 Test Questions and
Correct Answers
Decreased sleep leads to... ✅increased risk for delirium
Most common problem in ICU patients ✅anxiety: threat to health/life, loss of control of
body functions, foreign environment, lots of noise, pain, can't communicate
How to promote sleep in ICU ✅scheduled rest p periods, dim lights at night, provide
eye mask/ear plugs, open curtains during day, take measurements without disturbing
patient, comfort measures (benzos)
Causes of delirium ✅sleep deprived, meds, sensory overload, anxiety, disease
processes (hypoxia)
Signs of delirium ✅altered mental status, psychomotor. Behaviors (restless/lethargic),
altered sleep/wake cycle, inattention
ABCDEF bundle for ICU management ✅A: assess, prevent, manage pain by using
tools to be used in daily patients. B: both spontaneous trials and breathing, provide
powerful meds when needed, but stopping to prevent unwanted side effects. C: choice
of analgesia and sedation, using evidence to assess safest agents to use and ones to
avoid in a patient. D: delirium: assess, prevent, and manage. E: early mobility and
exercise to decrease delirium, decrease days on mechanical ventilation, and decrease
ICU hospital stay. F: family empowerment: open communication and clear e
expectations about recovery
Which assessment is used for delirium in ICU? ✅CAAM-ICU: confusion assessment
method for ICU
Common meds that are titrated ✅vasoactive agents, analgesics, sedatives.
Info in a titration med order ✅name, route, initial infusion rate, incremental units rate
can be increased/decreased, frequency for incremental doses, max rate, clinical
endpoint explained.
What response does pain elicit? ✅sympathetic nervous system
Cutaneous stimulation ✅heat, cold, vibration, massage (back massage promotes
sleep and relaxation), TENS (transcutaneous nerve stimulation)
, Sedation indications in ICU ✅to minimize discomfort/pain in procedures, safety,
minimize psychological disturbances, maximize amnesia if appropriate, control behavior
Common sedation drugs ✅midazolam and propofol
Common reasons for sedation ✅mechanical ventilation/reduce external stimuli from
stressing out an unstable patient
Midazolam ✅benzo of choice. Potential for tolerance/withdrawal, anterograde
amnesia, watch out for respiratory depression
Propofol ✅rapid offset, (lipid-watch triglycerides and cholesterol levels), watch out for
hypotension and Resp. Depression
Goal RAAS ✅0 to -2
Dexmedetomidine (Precedex) ✅alpha adrenergic receptor agonist in ICU for sedation
Best practice for sedation ✅control pain before sedation, because this may eliminate
need to sedate if pain med calms them down. Sedation interruptions/light target
sedation , non-pharm interventions to promote sleep, control light/noise, cluster care,
decrease stimuli at night
S/P ✅status post (talking about the condition that indicated treatment). Patient has
already experienced something medical
Intubated patient has IV fentanyl drip of 25 mcg/hr with: HR: 130, BP: 140/90, RR: 29,
ventilator alarming. Hands clenched, brow narrowed, patient eyes open and looking at
you anxiously. What should you do first? ✅ask the patient: "are you in pain?" want to
gather further assessment data
What type of problem? Q: everything looks normal, but HR is over 100 bpm or less than
60 bpm ✅SA node problem
What type of problem?: P-wave absent/abnormal, but QRS is normal. ✅atrial problem
(ex: SVT, a-fib, PAC)
What type of problem?: PR interval is too long or inconsistent, ratio of P-waves to QRS
interval is abnormal ✅AV node problem! The ratio of P to QRS complexes is greater
than 1:1 in both 2nd and 3rd degree blocks
Problem?: QRS wider than 0.12 seconds/3 small boxes ✅ventricular problem! Ex: VT,
v-fib, pvcs
