Chapter 01: Overview of Critical Care Nursing
Sole: Introduction to Critical Care Nursing, 8th Edition

MULTIPLE CHOICE

	1.	Which of the following professional organizations best supports critical care nursing practice?
a.	American Association of Critical-Care Nurses	
b.	American Heart Association	
c.	American Nurses Association	
d.	Society of Critical Care Medicine	

ANS:	A
The American Association of Critical-Care Nurses is the specialty organization that supports and represents critical care nurses. The American Heart Association supports cardiovascular initiatives. The American Nurses Association supports all nurses. The Society of Critical Care Medicine represents the multiprofessional critical care team under the direction of an intensivist.

DIF:	Cognitive Level: Knowledge	
OBJ:	Discuss the purposes and functions of the professional organizations that support critical care practice.	TOP:	Nursing Process Step: N/A	
MSC:	NCLEX: Safe and Effective Care Environment

	2.	A nurse has been working as a staff nurse in the surgical intensive care unit for 2 years and is interested in certification. Which credential would be most applicable for her to seek?
a.	ACNPC	
b.	CCNS	
c.	CCRN	
d.	PCCN	

ANS:	C
The CCRN certification is appropriate for nurses in bedside practice who care for critically ill patients. The ACNPC certification is for acute care nurse practitioners. The CCNS certification is for critical care clinical nurse specialists. The PCCN certification is for staff nurses working in progressive care, intermediate care, or step-down unit settings.

DIF:	Cognitive Level: Application	
OBJ:	Explain certification options for critical care nurses.	TOP:	Nursing Process Step: N/A
MSC:	NCLEX: Safe and Effective Care Environment

	3.	What is the main purpose of certification for critical care nursing?
a.	To assure the consumer that critical nurses will not make a mistake.	
b.	To help prepare the critical care nurse for graduate school.	
c.	To assist in promoting magnet status for a facility.	
d.	To validate a nurse’s knowledge of critical care nursing.	

ANS:	D
Certification assists in validating knowledge of the field, promotes excellence in the profession, and helps nurses to maintain their knowledge of critical care nursing. Certification helps to assure the consumer that the nurse has a minimum level of knowledge; however, it does not ensure that care will be mistake-free. Certification does not prepare one for graduate school; however, achieving certification demonstrates motivation for achievement and professionalism. Magnet facilities are rated on the number of certified nurses; however, that is not the purpose of certification.

DIF:	Cognitive Level: Analysis	
OBJ:	Explain certification options for critical care nurses.	TOP:	Nursing Process Step: N/A
MSC:	NCLEX: Safe and Effective Care Environment

	4.	What is the focus of the synergy model of practice?
a.	Allowing unrestricted visiting for the patient 24 hours each day.	
b.	Providing holistic and alternative therapies.	
c.	Considering the needs of patients and their families, which drives nursing competency.	
d.	Addressing the patients’ needs for energy and support.	

ANS:	C
The synergy model of practice states that the needs of patients and families influence and drive competencies of nurses. Nursing practice based on the synergy model would involve tailored visiting to meet the patient’s and family’s needs and application of alternative therapies if desired by the patient, but that is not the primary focus of the model.

DIF:	Cognitive Level: Application	
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: N/A	MSC:	NCLEX: Safe and Effective Care Environment

	5.	The family of your critically ill patient tells you that they have not spoken with the physician in over 24 hours and they have some questions that they want clarified. During morning rounds, you convey this concern to the attending intensivist and arrange for her to meet with the family at 4:00 PM in the conference room. Which competency of critical care nursing does this represent?
a.	Advocacy and moral agency in solving ethical issues	
b.	Clinical judgment and clinical reasoning skills	
c.	Collaboration with patients, families, and team members	
d.	Facilitation of learning for patients, families, and team members	

ANS:	C
Although one might consider that all of these competencies are being addressed, communication and collaboration with the family and physician best exemplify the competency of collaboration.

DIF:	Cognitive Level: Analysis	
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: N/A	MSC:	NCLEX: Safe and Effective Care Environment

	6.	The AACN Standards for Acute and Critical Care Nursing Practice uses what framework to guide critical care nursing practice?
a.	Evidence-based practice	
b.	Healthy work environment	
c.	National Patient Safety Goals	
d.	Nursing process	

ANS:	D
The AACN Standards for Acute and Critical Care Nursing Practice delineate the nursing process as applied to critically ill patients: collect data, determine diagnoses, identify expected outcomes, develop a plan of care, implement interventions, and evaluate care. AACN promotes a healthy work environment, but this is not included in the Standards. The Joint Commission has established National Patient Safety Goals, but these are not the AACN Standards.

DIF:	Cognitive Level: Understand	
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: N/A	MSC:	NCLEX: Safe and Effective Care Environment

	7.	The charge nurse is responsible for making the patient assignments on the critical care unit. She assigns the experienced, certified nurse to care for the acutely ill patient diagnosed with sepsis who also requires continuous renal replacement therapy and mechanical ventilation. She assigns the nurse with less than 1 year of experience to two patients who are more stable. This assignment reflects implementation of what guiding framework?
a.	Crew resource management model	
b.	National Patient Safety Goals	
c.	Quality and Safety Education for Nurses (QSEN) model	
d.	Synergy model of practice	

ANS:	D
This assignment demonstrates nursing care to meet the needs of the patient. The synergy model notes that the nurse competencies are matched to the patient characteristics. Crew resource management concepts related to team training, National Patient Safety Goals are specified by The Joint Commission to promote safe care but do not incorporate the synergy model. The Quality and Safety Education for Nurses initiative involves targeted education to undergraduate and graduate nursing students to learn quality and safety concepts.

DIF:	Cognitive Level: Analysis	
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: N/A	MSC:	NCLEX: Safe and Effective Care Environment

	8.	The vision of the American Association of Critical-Care Nurses is a healthcare system driven by achieving what goal?
a.	Maintaining a healthy work environment.	
b.	Providing care from a multiprofessional team under the direction of a critical care physician.	
c.	Effectively meeting the needs of critically ill patients and families.	
d.	Creating respectful, healing, and humane environments.	

ANS:	C
The AACN vision is a healthcare system driven by the needs of critically ill patients and families where critical care nurses make their optimum contributions. AACN promotes initiatives to support a healthy work environment as well as respectful and healing environments, but that is not the organization’s vision. The SCCM promotes care from a multiprofessional team under the direction of a critical care physician.

DIF:	Cognitive Level: Knowledge	
OBJ:	Discuss the purposes and functions of the professional organizations that support critical care practice.	TOP:	Nursing Process Step: N/A	
MSC:	NCLEX: Safe and Effective Care Environment

	9.	What is the most important outcome of effective communication?
a.	Demonstrating caring practices to family members.	
b.	Ensuring that patient teaching is provided	
c.	Meeting the diversity needs of patients.	
d.	Reducing patient errors.	

ANS:	D
Many errors are directly attributed to faulty communication. Effective communication has been identified as an essential strategy to reduce patient errors and resolve issues related to patient care delivery. Communication may demonstrate caring practices, be used for patient/family teaching, and address diversity needs; however, the main outcome of effective communication is patient safety.

DIF:	Cognitive Level: Analysis	
OBJ:	Describe quality and safety initiatives related to critical care nursing.
TOP:	Nursing Process Step: N/A	MSC:	NCLEX: Safe and Effective Care Environment

	10.	The nurse is caring for a critically ill patient whose urine output has been low for 2 consecutive hours. After a thorough patient assessment, you call the primary care provider with the following report.
Dr. Smith, I’m calling about Mrs. P., your 65-year-old patient in CCU 10. Her urine output for the past 2 hours totaled only 40 mL. She arrived from surgery to repair an aortic aneurysm 4 hours ago and remains on mechanical ventilation. In the past 2 hours, her heart rate has increased from 80 to 100 beats per minute and her blood pressure has decreased from 128/82 to 100/70 mm Hg. She is being given an infusion of normal saline at 100 mL per hour. Her right atrial pressure through the subclavian central line is low at 3 mm Hg. Her urine is concentrated. Her BUN and creatinine levels have been stable and in normal range. Her abdominal dressing is dry with no indication of bleeding. My assessment suggests that Mrs. P. is hypovolemic and I would like you to consider increasing her fluids or giving her a fluid challenge. Using the SBAR model for communication, the information the nurse gives about the patient’s history and vital signs is appropriate for what part of the model?
a.	Situation	
b.	Background	
c.	Assessment	
d.	Recommendation	

ANS:	B
The history and vital signs are part of the background. Information regarding the low urine output is the situation. Information regarding possible hypovolemia is part of the nurse’s assessment, and the suggestion for fluids is the recommendation.

DIF:	Cognitive Level: Understand	
OBJ:	Describe quality and safety initiatives related to critical care nursing.
TOP:	Nursing Process Step: Assessment	MSC:	NCLEX: Safe and Effective Care Environment

	11.	The family members of a critically ill, 90-year-old patient bring in a copy of the patient’s living will to the hospital, which identifies the patient’s wishes regarding health care. The nurse discusses the contents of the living will with the patient’s physician. This is an example of implementation of which of the AACN Standards of Professional Performance?
a.	Acquires and maintains current knowledge of practice	
b.	Acts ethically on the behalf of the patient and family	
c.	Considers factors related to safe patient care	
d.	Uses clinical inquiry and integrates research findings in practice	

ANS:	B
Discussing end-of-life issues is an example of a nurse acting ethically on behalf of the patient and family. The example does not relate to acquiring knowledge, promoting patient safety, or using research in practice.

DIF:	Cognitive Level: Analysis	
OBJ:	Describe standards of care and performance for critical care nursing.
TOP:	Nursing Process Step: Implementation		
MSC:	NCLEX: Safe and Effective Care Environment

	12.	Which of the following assists the critical care nurse in ensuring that care is appropriate and based on research?
a.	Clinical practice guidelines	
b.	Computerized physician order entry	
c.	Consulting with advanced practice nurses	
d.	Implementing Joint Commission National Patient Safety Goals	

ANS:	A
Clinical practice guidelines are being implemented to ensure that care is appropriate and based on research. Some physician order entry pathways, but not all, are based on research recommendations. Some advanced practice nurses, but not all, are well versed in evidence-based practices. The National Patient Safety Goals are recommendations to reduce errors using evidence-based practices.

DIF:	Cognitive Level: Analysis	
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: N/A	MSC:	NCLEX: Safe and Effective Care Environment

	13.	Comparing the patient’s current (home) medications with those ordered during hospitalization and communicating a complete list of medications to the next care provider when the patient is transferred within an organization or to another setting are strategies toward best achieving what patient related goal?
a.	Improving accuracy of patient identification.	
b.	Preventing errors related to look-alike and sound-alike medications.	
c.	Reconciling medications across the continuum of care.	
d.	Reducing harms associated with administration of anticoagulants.	

ANS:	C
These are steps recommended in the National Patient Safety Goals to reconcile medications across the continuum of care. Improving accuracy of patient identification is another National Patient Safety Goal. Preventing errors related to look-alike and sound-alike medications is done to improve medication safety, not medication reconciliation. Reducing harms associated with administration of anticoagulants is another National Patient Safety Goal.

DIF:	Cognitive Level: Comprehension	
OBJ:	Describe quality and safety initiatives related to critical care nursing.
TOP:	Nursing Process Step: N/A	MSC:	NCLEX: Safe and Effective Care Environment

	14.	As part of nursing management of a critically ill patient, orders are written to keep the head of the bed elevated at 30 degrees, awaken the patient from sedation each morning to assess readiness to wean from mechanical ventilation, and implement oral care protocols every 4 hours. These interventions are done as a group to reduce the risk of ventilator-associated pneumonia. This group of evidence-based interventions is often referred to using what term?
a.	Bundle of care.	
b.	Clinical practice guideline.	
c.	Patient safety goal.	
d.	Quality improvement initiative.	

ANS:	A
A group of evidence-based interventions done as a whole to improve outcomes is termed a bundle of care. This is an example of the ventilator bundle. Oftentimes these bundles are derived from clinical practice guidelines and are monitored for compliance as part of quality improvement initiatives. At some point, these may become part of patient safety goals.

DIF:	Cognitive Level: Analysis	
OBJ:	Describe quality and safety initiatives related to critical care nursing.
TOP:	Nursing Process Step: Implementation		
MSC:	NCLEX: Safe and Effective Care Environment

	15.	A nurse who works in an intermediate care unit has experienced high nursing turnover. The nurse manager is often considered to be an autocratic leader by staff members and that leadership style is contributing to turnover. The nurse asks to be involved in developing new guidelines to prevent pressure ulcers in the patient population. The nurse manager suggests that the nurse has not yet had enough experience to be on the prevention task force. This situation and setting is an example of what form of ineffective leadership?
a.	Creating a barrier to inter-staff communication.	
b.	Supporting a work environment that is unhealthy.	
c.	Displaying ineffective decision making.	
d.	Demonstrating nursing practice that is not evidence-based.	

ANS:	B
These are examples of an unhealthy work environment. A healthy work environment values communication, collaboration, and effective decision making. It also has authentic leadership. It is not an example of handoff communication, which is communication that occurs to transition patient care from one staff member to another. Neither does it relate to ineffective decision making. As a nurse, you can still implement evidence-based practice, but your influence in the unit is limited by the unhealthy work environment.

DIF:	Cognitive Level: Analysis	
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: N/A	MSC:	NCLEX: Safe and Effective Care Environment

	16.	Which of the following statements describes the core concept of the synergy model of practice?
a.	All nurses must be certified in order to have the synergy model implemented.	
b.	Family members must be included in daily interdisciplinary rounds.	
c.	Nurses and physicians must work collaboratively and synergistically to influence care.	
d.	Unique needs of patients and their families influence nursing competencies.	

ANS:	D
The synergy model of practice is care based on the unique needs and characteristics of the patient and family members. Although critical care certification is based on the synergy model, the model does not specifically address certification. Inclusion of family members into the daily rounds is an example of implementation of the synergy model. With the focus on patients and family members with nurse interaction, the synergy model does not address physician collaboration.

DIF:	Cognitive Level: Application	
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: Implementation		
MSC:	NCLEX: Psychosocial Integrity

	17.	A nurse who plans care based on the patient’s gender, ethnicity, spirituality, and lifestyle is said to demonstrate what focus?
a.	Becoming a moral advocate.	
b.	Facilitating all forms of learning.	
c.	Responding to diversity.	
d.	Using effective clinical judgment.	

ANS:	C
Response to diversity considers all of these aspects when planning and implementing care. A moral agent helps resolve ethical and clinical concerns. Consideration of these factors does not necessarily facilitate learning. Clinical judgment uses other factors as well.

DIF:	Cognitive Level: Comprehension	
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: Planning	MSC:	NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE

	1.	Which of the following is a National Patient Safety Goal? (Select all that apply.)
a.	Accurately identify patients.	
b.	Eliminate use of patient restraints.	
c.	Reconcile medications across the continuum of care.	
d.	Reduce risks of healthcare-acquired infection.	

ANS:	A, C, D
All except for eliminating use of restraints are current National Patient Safety Goals. Hospitals have policies regarding use of restraints and are attempting to reduce the use of restraints; however, this is not a National Patient Safety Goal.

DIF:	Cognitive Level: Knowledge	
OBJ:	Describe quality and safety initiatives related to critical care nursing.
TOP:	Nursing Process Step: N/A	MSC:	NCLEX: Safe and Effective Care Environment

	2.	Which of the following is (are) official journal(s) of the American Association of Critical-Care Nurses? (Select all that apply.)
a.	American Journal of Critical Care	
b.	Critical Care Clinics of North America	
c.	Critical Care Nurse	
d.	Critical Care Nursing Quarterly	

ANS:	A, C
American Journal of Critical Care and Critical Care Nurse are two official AACN publications. Critical Care Clinics and Critical Care Nursing Quarterly are not AACN publications.

DIF:	Cognitive Level: Knowledge	
OBJ:	Discuss the purposes and functions of the professional organizations that support critical care practice.	TOP:	Nursing Process Step: N/A	
MSC:	NCLEX: Safe and Effective Care Environment

	3.	What were identified as the first critical care units? (Select all that apply.)
a.	Burn units.	
b.	Coronary care units	
c.	Recovery rooms.	
d.	Neonatal intensive care units.	
e.	High-risk OB units.	

ANS:	B, C
Recovery rooms and coronary care units were the first units designated to care for critically ill patients. Burn, high risk OB and neonatal intensive care units were established as specialty units evolved.

DIF:	Cognitive Level: Knowledge	OBJ:	Define critical care nursing.
TOP:	Nursing Process Step: N/A	MSC:	NCLEX: Safe and Effective Care Environment

	4.	Which of the following nursing activities demonstrates implementation of the AACN Standards of Professional Performance? (Select all that apply.)
a.	Attending a meeting of the local chapter of the American Association of Critical-Care Nurses in which a continuing education program on sepsis is being taught	
b.	Collaborating with a pastoral services colleague to assist in meeting spiritual needs of the patient and family	
c.	Participating on the unit’s nurse practice council	
d.	Posting an article from Critical Care Nurse on management of venous thromboembolism for your colleagues to read	
e.	Using evidence-based strategies to prevent ventilator-associated pneumonia	

ANS:	A, B, C, D, E
All answers are correct. Attending a program to learn about sepsis—Acquires and maintains current knowledge and competency in patient care. Collaborating with pastoral services—Collaborates with the healthcare team to provide care in a healing, humane, and caring environment. Posting information for others—Contributes to the professional development of peers and other healthcare providers. Nurse practice council—Provides leadership in the practice setting. Evidence-based practices—Uses clinical inquiry in practice.

DIF:	Cognitive Level: Analysis	
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: N/A	MSC:	NCLEX: Safe and Effective Care Environment

	5.	Which scenarios contribute to effective handoff communication at change of shift? (Select all that apply.)
a.	The nephrology consultant physician is making rounds and asks the nurse to provide an update on the patient’s status and assist in placing a central line for hemodialysis.	
b.	The noise level is high because twice as many staff members are present and everyone is giving report in the nurse’s station.	
c.	The unit has decided to use a standardized checklist/tool for change-of-shift reports and patient transfers.	
d.	Both the off-going and the oncoming nurses conduct a standardized report at the patient’s bedside and review key assessment findings.	
e.	The off-going nurse is giving the patient medications at the same time as giving handoff report to the oncoming nurse.	

ANS:	C, D
A reporting tool and bedside report improve handoff communication by ensuring standardized communication and review of assessment findings. Conducting report at the bedside also reduces noise that commonly occurs at the nurse’s station during a change of shift. The nephrologist has created an interruption that can impede handoff with the next nurse. Likewise, noise in the nurse’s station can cause distractions that can impair concentration and listening. Giving medications at the same time as handoff report could lead to serious errors both in medication administration and in the report itself.

DIF:	Cognitive Level: Analysis	
OBJ:	Describe quality and safety initiatives related to critical care nursing.
TOP:	Nursing Process Step: N/A	MSC:	NCLEX: Safe and Effective Care Environment

	6.	Which strategy is important to addressing issues associated with the aging workforce? (Select all that apply.)
a.	Allowing nurses to work flexible shift durations	
b.	Encouraging older nurses to transfer to an outpatient setting that is less stressful	
c.	Hiring nurse technicians that are available to assist with patient care, such as turning the patient	
d.	Developing a staffing model that accurately reflects the unit’s needs.	
e.	Remodeling patient care rooms to include devices to assist in patient lifting	

ANS:	A, C, D
Modifying the work environment to reduce physical demands is one strategy to assist the aging workforce. Examples include overhead lifts to prevent back injuries. Twelve-hour shifts can be quite demanding; therefore, allowing nurses flexibility in choosing shifts of shorter duration is a good option as well. Adequate staffing, including non-licensed assistive personnel, to help with nursing and non-nursing tasks is helpful. Encouraging experienced, knowledgeable critical care nurses to leave the critical care unit is not wise as the unit loses the expertise of this group.

DIF:	Cognitive Level: Analysis	
OBJ:	Identify current trends and issues in critical care nursing.	TOP:	Nursing Process Step: N/A
MSC:	NCLEX: Safe and Effective Care Environment

	7.	Which of the following strategies will assist in creating a healthy work environment for the critical care nurse? (Select all that apply.)
a.	Celebrating improved outcomes from a nurse-driven protocol with a pizza party	
b.	Implementing a medication safety program designed by pharmacists	
c.	Modifying the staffing pattern to ensure a 1:1 nurse/patient ratio	
d.	Offering quarterly joint nurse-physician workshops to discuss unit issues	
e.	Using the Situation-Background-Assessment-Recommendation (SBAR) technique for handoff communication	

ANS:	A, D, E
Meaningful recognition, true collaboration, and skilled communication are elements of a healthy work environment. Implementing a medication safety program enhances patient safety, and if done without nursing input, could have negative outcomes. Staffing should be adjusted to meet patient needs and nurse competencies, not have predetermined ratios that are unrealistic and possibly not needed.

DIF:	Cognitive Level: Analysis	
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: Implementation		
MSC:	NCLEX: Safe and Effective Care Environment