Competencies & Best Practices for Acute & Critical Care Nurses: AACN & SCCM Perspectives, Exams of Nursing

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NR 341 - Exam 1 Qustions and answers

Critical Care Nursing \correct answer✅- deals with human responses to critical illness

• focus on both the patient's and family's responses Evolution of Critical Care \correct answer✅- began with polio units, recovery rooms, and coronary care units
• patient outcomes have improved eICU \correct answer✅a new application of critical care from a remote monitoring site Competencies for Acute and Critical Care Nurses \correct answer✅- clinical reasoning
• advocacy
• caring
• collaboration
• holistic nursing care
• response to diversity American Association of Critical Care Nurses \correct answer✅- largest specialty organization
• assists NURSES to attain knowledge and influence
• healthy work environment initiative AACN's Vision \correct answer✅create a healthcare system driven by patient's and family's needs in which critical care nurses make their optimum contributions AACN: Professional Journals \correct answer✅- Critical Care Nurse
• American Journal of Critical Care
• AACN Advanced Critical Care AACN Membership Benefits \correct answer✅- professional journals
• evidence-based interventions
• continuing education Society of Critical Care Medicine \correct answer✅- multiprofessional membership
• healthcare system in which all critically ill and injured persons receive care Synergy Model \correct answer✅nurses are assigned patients based on their acuity and level of experience of critical care nurses on duty Critical Care Certification \correct answer✅- validate knowledge
• promote professional excellence
• help nurses maintain up to date knowledge

• AACN oversees this CCRN \correct answer✅adult, neonatal and pediatric intensive care PCCN \correct answer✅for those working in step-down units CCNS \correct answer✅Critical Care Clinical Nurse Specialist (Advanced Practice) ACNPC \correct answer✅Acute Care Nurse Practitioner Critical Care Patients \correct answer✅- multisystem organ dysfunction
• complicated by aging population Joint Commission \correct answer✅- national patient safety goals
• communication
• medication safety
• reduce infections
• reconcile medications AACN Hierarchy of Evidence \correct answer✅A is the most supported and M is the least supported Collaboration \correct answer✅create a culture of safety where everyone works together Critical Care Environment \correct answer✅- designed for efficient, lifesaving interventions
• patients and families are typically stressed and anxious Sensory Overload \correct answer✅- light
• noise
• loss of privacy
• multiple caregivers in and out of the room Loudest Activity \correct answer✅Pneumatic Tube Arrival Modification of Environment \correct answer✅- noise reduction (soothing music, private areas)
• adequate lighting (natural lighting, night day synchronization)
• design new units to promote health and safety Psychosocial Support \correct answer✅- ensure safety
• reduce sleep deprivation
• reduce sensory overload
• increase pleasant sensory input
• provide reorientation

Discharge from Critical Care \correct answer✅- fear of abandonment

• learn new routines
• new staff
• new roommates
• prepare patients Post Critical Care Symptoms \correct answer✅- fatigue, sleep disturbance
• pain, muscle weakness
• poor concentration
• poor appetite
• PTSD Geriatric Concerns \correct answer✅- diminished ability to adapt or cope with stressors
• greater risk for negative outcomes Calgary Family Assessment \correct answer✅- structural (decision maker)
• developmental (stage)
• functional (how they interact) EPICS Approach: Addressing Family Needs \correct answer✅- Evaluate
• Plan
• Involve
• Communicate
• Support VALUE: Addressing Family Needs \correct answer✅- Value what they tell you
• Acknowledge emotions
• Listen to family
• Understand the patient as a person
• Elicit questions form family members Family Present During Codes \correct answer✅allows them to witness everything that has been done Ethical Decision Making Process \correct answer✅- assess
• consider options
• develop plan with patient
• act on plan
• evaluate plan Advocacy \correct answer✅- open communication of patient's wishes and ethical concerns
• true collaboration with healthcare team members Formal Mechanisms: Joint Commission \correct answer✅- bioethics committee
• ethics consultation

Preventing Abandonment \correct answer✅- severing professional relationship when patient

• ensure that patient care is arranged with another nurse during breaks Elements of Informed Consent \correct answer✅- Competence
• Voluntariness
• Disclosure of Information Life Sustaining Treatment: Factors to Consider \correct answer✅- constitutional rights
• quality of life
• impact of advanced technology
• ordinary for extraordinary care Ordinary Care \correct answer✅- common, noninvasive, and tested treatment
• nutrition, hydration and antibiotics Extraordinary Care \correct answer✅- complex, invasive, experimental treatments
• ACLS, dialysis, unproved therapies What is in between ordinary and extraordinary care? \correct answer✅feeding tube for hydration CPR Issues \correct answer✅- DNR is needed to not initiate a code
• advance directives are useful
• family presence during codes is promoted Withholding \correct answer✅not initiating Withdrawal \correct answer✅weaning or removing Helping Families make Decisions \correct answer✅- communicate frequently
• engage in consistent, honest communication
• base decisions on patient's wishes
• provide support Self Determination Act \correct answer✅- right to initiate advance directive
• right to consent or refuse treatment Advance Directive \correct answer✅- communication about preference for treatments if patient is incapacitated
• living will (treatment desired and withheld)
• durable power of attorney for health care Organ and Tissue Transplantation \correct answer✅- brain dead are often candidates
• everyone has a right to donate organs

• conflict of patient's designation versus family member's view
• designated requestors seek consent Living Will \correct answer✅treatment desired and what should be withheld Durable Power of Attorney for Health Care \correct answer✅- determines who makes decisions
• healthcare surrogate or proxy Medical Futility \correct answer✅situation in which therapy or interventions will not provide a foreseeable possibility to improve the patient's health Palliative Care \correct answer✅- designed to relieve symptoms that negatively affect patient and family
• implemented with all patients, not just the dying Nursing Interventions for Palliative Care \correct answer✅- frequent repositioning
• good hygiene
• skin care
• creation of peaceful environment
• pain relief Terminal Weaning \correct answer✅- ventilator withdrawal
• titrate pain medications and sedation during process, relieves tachypnea, dyspnea and use of accessory muscles Nursing Interventions During Withdrawal or Withholding of Treatment \correct answer✅- provide anticipatory guidance to patient and family
• anticipate distressing symptoms and medicate to relieve symptoms
• titrate therapy to relieve emotional and physical distress Hospice \correct answer✅- comfort rather than cure
• dying is normal
• philosophy of care not location
• common in oncology Characteristics of Pain \correct answer✅- precipitating cause
• severity
• location and radiation
• duration
• alleviating or aggravating factors EEG Values \correct answer✅- 0 (flat EEG)
• 100 (awake)
• 40-60 (deep sedation plus amnesia)

Delirium \correct answer✅- CAM - ICU

• keep patient safe
• haloperidol ABCDE Delirium Bundle \correct answer✅- awakening
• breathing coordination
• choice of sedation
• delirium monitoring
• early mobility Fetanyl \correct answer✅fastest onset Morphine \correct answer✅longest duration Epidural \correct answer✅- opioid or local anesthetic
• facilitates mobility and pulmonary hygiene NSAIDS \correct answer✅- decrease need for opioid
• risks of GI bleeding and renal (ibuprofen) or liver (acetaminophen) insufficiency Pharmacological Treatment for Anxiety \correct answer✅- benzodiazepine
• propofol
• dexmedetomidine Ventilation \correct answer✅movement of O2 and CO2 in and out of the alveoli Oropharyngeal Sizing \correct answer✅- hold airway against side of patients face
• extend from the corner of the patient's mouth to the angle of the jaw Oropharyngeal \correct answer✅- keeps tongue from falling back and blocking the upper airway
• used in unresponsive patients with no gag reflex Oropharyngeal Airway Insertion \correct answer✅- open mouth
• insert with tip pointing up to avoid pushing tongue back
• once tip reaches soft palate, rotate 180 degrees
• top should rest on patient's lips Nasopharyngeal Airways \correct answer✅- curved, flexile rubber or plastic tubes inserted into nostril
• used on responsive patients
• relieves upper airway obstruction and facilitates passage of suction catheter Nasopharyngeal Airway Insertion \correct answer✅- lubricate and insert into nostril that appears most open
• insert until the flange is against the nostril opening

• check to ensure airflow
• good if they need to be suctioned frequently Suctioning \correct answer✅- suction intermittenly (10-15 sec)
• suction only as far into the mouth as you can see and only when catheter is withdrawn
• suction only as far into the nose as the distance from the tip of the nose to the earlobe
• pre oxygenate before suctioning Hypoxemic Respiratory Failure Type 1 \correct answer✅- when you don't have enough oxygen in your blood but your levels of carbon dioxide are close to normal
• PaO2 <60 mmHg
• PaCO2 normal Hypercapnic Respiratory Failure Type 2 \correct answer✅- when there's too much CO in your blood and near normal or not enough oxygen
• PaCO2 >50 mmHg
• < 7. Indications for Mechanical Ventilation \correct answer✅- airway compromise
• respiratory failure
• need to protect the airway Acute Respiratory Failure \correct answer✅- Ventilation/Perfusion (V/Q) mismatch
• results when lungs cannot adequately oxygenate or eliminate CO Acute Respiratory Failure Interventions \correct answer✅- treat the underlying cause
• support
• ensure comfort, pain control and psychological support Acute Respiratory Distress Syndrome \correct answer✅- direct or indirect injury
• death can occur in 48 hours Oscillatory Ventilation \correct answer✅- Delivers low tidal volume at fast rate (300- bpm)
• used in patients with noncompliant lungs (ARDS)
• close monitoring
• sedation and paralysis indicated ARDS Interventions \correct answer✅- sedation and comfort
• oxygenation
• prone
• fluids and electrolytes
• nutrition Contraindications for an Artificial Airway \correct answer✅when a patient has a DNR order

Intubation Procedure \correct answer✅- pre-oxygenate 100%

• do not allow more than 30 second attempts
• not successful wait 3-5 minutes before reattempt Intubation: Confirming Tube Position \correct answer✅- auscultation
• bilateral chest rise
• tube location at teeth
• CO2 detector (gold is good)
• XRAY Ventilatory Associated Pneumonia (VAP) \correct answer✅- 10-20% develop VAP
• mortality can be as high as 80%
• only with patients on ventilators VAP Bundle \correct answer✅- HOB 30-45 degrees
• interrupt sedation daily to assess readiness to wean
• provide daily oral care with chlorhexidine
• provide prophylaxis for DVT and PUD Nasoendotracheal Advantages \correct answer✅- comfortable for prolonged intubation
• suitable for oral surgery
• blind intubation
• can take oral feedings
• resists kinking Nasoendotracheal Disadvantages \correct answer✅- trauma to nasal mucosa
• risk for sinusitis
• risk for bacteremia
• smaller diameter than oral route Contraindications for Nasoendotracheal Intubation \correct answer✅- basilar skull fracture
• coagulopathy
• nasal cavity obstruction
• retropharyngeal abscess Tracheostomy \correct answer✅- allows person to breath without nose or mouth
• used primarily in situation where a prolonged need for airway support is anticipated Assist/Control Mode \correct answer✅- delivers preset volumes, rate and flow rate
• patient cannot generate spontaneous volumes
• each patient generated respiratory effort over the above set rate is delivered the set volume and flow rate

Synchronized Intermittent Mandatory Ventilation \correct answer✅- delivers a pre-set number of breaths at a set volume and flow rate

• allows patient to generate spontaneous breaths
• detects patient breaths and doesn't initiate ventilatory breath
• weaning Positive End Expiratory Pressure (PEEP) \correct answer✅- amount of pressure remaining in the lung at the end of expiratory phase
• 5- Continuous Positive Airway Pressure \correct answer✅- a preset pressure is present in the circuit and lungs throughout both inspiratory and expiratory phases
• keeps alveoli from collapsing
• patient must be spontaneously breathing
• used in conjunction with weaning Anxious Patient: Ventilation \correct answer✅- malfunction of ventilator
• patient may need to be suctioned
• frequently the patient needs medication Low Pressure Alarm \correct answer✅- attempt to quickly find the problem
• usually due to a leak in the circuit
• bag the patient High Pressure Volume \correct answer✅- blockage in the circuit
• patient biting ETT
• mucus plug
• patient coughing
• bag patient Low Minute Volume Alarm \correct answer✅- apnea (CPAP)
• disconnection of the patient from the ventilator
• bag patient Accidental Extubation \correct answer✅- ensure ambu bag is attached to oxygen and it is on
• attach face mask to ambu bag
• ensure good seal
• supply patient with ventilation Norcuron (Cecuronium Bromide) \correct answer✅neuromuscular blocking agent Dexamethasone \correct answer✅corticosteroid that prevents the release of substance in the body that cause inflammation

Ipratropium \correct answer✅relaxes muscles around the airways so that they open up and you can breath easily Rapid Response \correct answer✅- failure to recognize causes death

• implemented to address changes in condition before cardiac or respiratory arrest When to call RRT? \correct answer✅changes in
• heart rate, systolic BP
• RR, oxygen saturation
• mental status
• urinary output
• lab values Code Blue \correct answer✅- cardiac or respiratory arrest
• lifesaving resuscitation and intervention needed Sequence of Events: BLS \correct answer✅- advance directives
• airway open
• breathing (O2)
• chest compressions ACLS: Airway and Breathing \correct answer✅- airway management
• manual ventilation
• intubation
• delivery of tidal volume Bag Valve Mask \correct answer✅- connected to an oxygen source set at 15L/min
• ever 5-6 seconds ACLS: Circulation \correct answer✅- large bore IV's
• biggest veins
• may insert central line
• intraosseous if IV access is difficult Normal pH \correct answer✅7.35-7. Acidotic \correct answer✅<7. Alkalotic \correct answer✅>7. Normal PaCO2 \correct answer✅35- Respiratory Acidosis \correct answer✅> Respiratory Alkalosis \correct answer✅<

Normal HCO3 \correct answer✅22- Metabolic Acidosis \correct answer✅< Metabolic Alkalosis \correct answer✅> Compensated \correct answer✅pH is normal and PaCo2 and HCO3 are both abnormal Partially Compensated \correct answer✅pH is abnormal and PaCO2 and HCO3 are both abnormal Uncompensated \correct answer✅PaCO2 or HCO3 are abnormal and pH is abnormal Intubation Equipment \correct answer✅- o2 flowmeter and o2 tubing

• suction apparatus
• suction catheter
• ambu bag
• laryngoscope
• stylet
• stethoscope
• tape
• syringe
• magil forceps
• towels for position What you need to know about your intubation \correct answer✅- mode
• size
• position at the teeth Leader of the Code \correct answer✅- physician
• directs code
• makes diagnoses and treatment decisions Primary Nurse \correct answer✅- provides info
• measures vitals
• assists with procedures
• administers meds Second Nurse \correct answer✅- coordinates crash cart
• prepares meds
• assembles equipment Nursing Supervisor \correct answer✅- controls crowd
• contacts attending physician
• assists with meds and procedures
• ensures a bed is available it critical care

• assists with transfer Nurse or Assistant \correct answer✅records events Role of Nurse During Intubation \correct answer✅- makes sure RSI available
• inform patient what is going on
• preoxygenate patient Reversible Causes of Cardiac Arrest: H \correct answer✅- hypovolemia (decreased amount of circulating blood)
• hypoxia
• hydrogen ion (acidosis)
• hypo/hyperkalemia
• hypothermia Reversible Causes of Cardiac Arrest: T \correct answer✅- tension pneumothorax
• tamponade (fluid collecting in sac around heart)
• toxins
• thrombosis Epinephrine \correct answer✅- vasoconstrictor
• increases everything
• indicated for the restoration of cardiac electrical activity
• given every 3-5 min, 1 mg Atropine \correct answer✅- increase heart rate by decreasing vagal tone
• indicated for patients with symptomatic bradycardia Vasopressin \correct answer✅intense vasoconstriction may be as effective as epi Dopamine \correct answer✅- used for symptomatic hypotension in the absence of hypovolemia
• second line medication for symptomatic bradycardia after atropine
• used to increase BP Causes of ARF \correct answer✅- hypoventilation
• intrapulmonary shunting
• ventilation-perfusion mismatching
• diffusion defects