Chapter 01: Overview of Critical Care Nursing
Sole: Introduction to Critical Care Nursing, 7th 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: Remember/Knowledge		REF:	p. 5
OBJ:	Discuss the purposes and functions of the professional organizations that support critical care practice.	TOP:	Nursing Process Step: N/A	
MSC:	NCLEX Client Needs Category: 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 the nurse to seek?
a.	ACNPC-AG	
b.	CNML	
c.	CCRN	
d.	PCCN	

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

DIF:	Cognitive Level: Remember/Knowledge		REF:	p. 6
OBJ:	Explain certification options for critical care nurses.	TOP:	Nursing Process Step: N/A
MSC:	NCLEX Client Needs Category: Safe and Effective Care Environment

	3.	The main purpose of certification is to
a.	assure the consumer that you will not make a mistake.	
b.	prepare for graduate school.	
c.	promote magnet status for your facility.	
d.	validate 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: Remember/Knowledge		REF:	p. 6
OBJ:	Explain certification options for critical care nurses.	TOP:	Nursing Process Step: N/A
MSC:	NCLEX Client Needs Category: Safe and Effective Care Environment

	4.	The synergy model of practice focuses on
a.	allowing unrestricted visiting for the patient 24 hours a day.	
b.	holistic and alternative therapies.	
c.	the needs of patients and their families, which drive nursing competency.	
d.	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 the application of alternative therapies if desired by the patient, but that is not the primary focus of the model.

DIF:	Cognitive Level: Remember/Knowledge		REF:	p. 6
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: N/A	
MSC:	NCLEX Client Needs Category: 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 that they have some questions they want clarified. During morning rounds, you convey this concern to the attending intensivist and arrange a meeting with the family at 4:00 PM. 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: Analyze/Analysis			REF:	p. 6 | Fig 1-3 | Box 1-1
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: N/A	
MSC:	NCLEX Client Needs Category: Safe and Effective Care Environment

	6.	The AACN Standards for Acute and Critical Care Nursing Practice use 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 its standards. The Joint Commission has established National Patient Safety Goals, but these are not the AACN standards.

DIF:	Cognitive Level: Remember/Knowledge		REF:	p. 6
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: N/A	
MSC:	NCLEX Client Needs Category: Safe and Effective Care Environment

	7.	The charge nurse is responsible for making the patient assignments on the critical care unit. An experienced, certified nurse is assigned to care for the acutely ill patient with sepsis who also requires continuous renal replacement therapy and mechanical ventilation. The nurse with less than 1 year of experience is assigned to two patients who are more stable. This assignment reflects implementation of the
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 are 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 of undergraduate and graduate nursing students on quality and safety concepts.

DIF:	Cognitive Level: Analyze/Analysis			REF:	p. 6
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: N/A	
MSC:	NCLEX Client Needs Category: Safe and Effective Care Environment

	8.	The vision of the American Association of Critical-Care Nurses is a health care system driven by
a.	a healthy work environment.	
b.	care from a multiprofessional team under the direction of a critical care physician.	
c.	the needs of critically ill patients and families.	
d.	respectful, healing, and humane environments.	

ANS:	C
The AACN vision is a health care 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 Society of Critical Care Medicine (SCCM) promotes care from a multiprofessional team under the direction of a critical care physician.

DIF:	Cognitive Level: Remember/Knowledge		REF:	p. 5
OBJ:	Discuss the purposes and functions of the professional organizations that support critical care practice.	TOP:	Nursing Process Step: N/A	
MSC:	NCLEX Client Needs Category: Safe and Effective Care Environment

	9.	The most important outcome of effective communication is to
a.	demonstrate caring practices to family members.	
b.	ensure that patient teaching is done.	
c.	meet the diversity needs of patients.	
d.	reduce 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, address diversity needs, and be used for patient/family teaching; however, the main outcome of effective communication is patient safety.

DIF:	Cognitive Level: Remember/Knowledge		REF:	p. 9
OBJ:	Describe quality and safety initiatives related to critical care nursing.
TOP:	Nursing Process Step: N/A	
MSC:	NCLEX Client Needs Category: Safe and Effective Care Environment

	10.	You are caring for a critically ill patient whose urine output has been low for 2 consecutive hours. After a thorough patient assessment, you call the intensivist with report. Which information do you convey regarding background?
a.	Urine output of 40 mL/2 hours	
b.	Current vital signs and history of aortic aneurysm repair 4 hours ago	
c.	A statement that the patient is possibly hypovolemic	
d.	A request for IV fluids	

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: Analyze/Analysis			REF:	p. 9
OBJ:	Describe quality and safety initiatives related to critical care nursing.
TOP:	Integrated Process: Communication			
MSC:	NCLEX Client Needs Category: Safe and Effective Care Environment

	11.	The family members of a critically ill patient bring a copy of the patient’s living will to the hospital, which identifies the patient’s wishes regarding health care. You discuss 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: Analyze/Analysis			REF:	p. 6 | Box 1-2
OBJ:	Describe standards of care and performance for critical care nursing.
TOP:	Nursing Process Step: Implementation		
MSC:	NCLEX Client Needs Category: 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: Analyze/Analysis			REF:	p. 8
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: N/A	
MSC:	NCLEX Client Needs Category: 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 provider when the patient is transferred within an organization or to another setting are strategies to:
a.	improve accuracy of patient identification.	
b.	prevent errors related to look-alike and sound-alike medications.	
c.	reconcile medications across the continuum of care.	
d.	reduce harms associated with the 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, but is not related to transferring the patient between settings. Reducing harms associated with the administration of anticoagulants is another National Patient Safety Goal.

DIF:	Cognitive Level: Understand/Comprehension	REF:	p. 7 | Box 1-3
OBJ:	Describe quality and safety initiatives related to critical care nursing.
TOP:	Nursing Process Step: N/A	
MSC:	NCLEX Client Needs Category: 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 called a
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: Remember/Knowledge		REF:	p. 7 | Box 1-3
OBJ:	Describe quality and safety initiatives related to critical care nursing.
TOP:	Nursing Process Step: Implementation		
MSC:	NCLEX Client Needs Category: Safe and Effective Care Environment

	15.	You work in an intermediate care unit and have asked to be involved in developing new guidelines to prevent pressure ulcers in your patient population. The nurse manager tells you that you do not yet have enough experience to be on the prevention task force and that your ideas will be rejected by others. This situation is an example of
a.	a barrier to handoff communication.	
b.	a work environment that is unhealthy.	
c.	ineffective decision making.	
d.	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: Analyze/Analysis			REF:	pp. 8-9
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: N/A	
MSC:	NCLEX Client Needs Category: 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: Apply/Application			REF:	p. 6
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Integrated Process: Caring	
MSC:	NCLEX Client Needs Category: Safe and Effective Care Environment

	17.	A nurse who plans care based on the patient’s gender, ethnicity, spirituality, and lifestyle is said to
a.	be a moral advocate.	
b.	facilitate learning.	
c.	respond to diversity.	
d.	use 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: Understand/Comprehension	REF:	p. 5
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: Planning	
MSC:	NCLEX Client Needs Category: 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 the use of patient restraints.	
c.	Reconcile medications across the continuum of care.	
d.	Reduce risks of health care–acquired infection.	
e.	Reduce costs associated with hospitalization.	

ANS:	A, C, D
All except for eliminating the use of restraints and reducing costs are current National Patient Safety Goals. Hospitals have policies regarding the use of restraints and are attempting to reduce the use of restraints; however, this is not a National Patient Safety Goal. Many facilities are actively working on cost reduction, but this is not a National Patient Safety Goal either.

DIF:	Cognitive Level: Remember/Knowledge		REF:	p. 7 | Box 1-3
OBJ:	Describe quality and safety initiatives related to critical care nursing.
TOP:	Nursing Process Step: N/A	
MSC:	NCLEX Client Needs Category: 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	
e.	Critical Care Nursing Management	

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

DIF:	Cognitive Level: Remember/Knowledge		REF:	p. 5
OBJ:	Discuss the purposes and functions of the professional organizations that support critical care practice.	TOP:	Nursing Process Step: N/A	
MSC:	NCLEX Client Needs Category: Safe and Effective Care Environment

	3.	The first critical care units were (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, neonatal intensive care, and high-risk OB units were established as specialty units evolved.

DIF:	Cognitive Level: Remember/Knowledge		REF:	p. 3
OBJ:	Define critical care nursing.	TOP:	Nursing Process Step: N/A
MSC:	NCLEX Client Needs Category: 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 the 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 health care team to provide care in a healing, humane, and caring environment. Posting information for others—Contributes to the professional development of peers and other health care providers. Nurse practice council—Provides leadership in the practice setting. Evidence-based practices—Uses clinical inquiry in practice.

DIF:	Cognitive Level: Remember/Knowledge		REF:	p. 4
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: N/A	
MSC:	NCLEX Client Needs Category: 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 you for an update on the patient’s status and to 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 nurses’ station.	
c.	The unit has decided to use a standardized checklist/tool for change-of-shift reports and patient transfers.	
d.	You and the oncoming nurse 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 nurses’ station during a change of shift. The nephrologist has created an interruption that can impede handoff with the next nurse. Likewise, noise in the nurses’ 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: Analyze/Analysis			REF:	pp. 9-10
OBJ:	Describe quality and safety initiatives related to critical care nursing.
TOP:	Nursing Process Step: N/A	
MSC:	NCLEX Client Needs Category: Safe and Effective Care Environment

	6.	Which strategy is important in 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 who are available to assist with patient care, such as turning the patient	
d.	Remodeling patient care rooms to include devices to assist in patient lifting	
e.	Developing a staffing model that accurately reflects the unit’s needs.	

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 both registered nurses and nonlicensed assistive personnel to help with nursing and nonnursing 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: Analyze/Analysis			REF:	pp. 16-17
OBJ:	Identify current trends and issues in critical care nursing.	TOP:	Nursing Process Step: N/A
MSC:	NCLEX Client Needs Category: 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, but if done without nursing input, it could have negative outcomes. Staffing should be adjusted to meet patient needs and nurse competencies, not have predetermined ratios that are unrealistic and possibly unneeded.

DIF:	Cognitive Level: Apply/Application			REF:	pp. 8-9
OBJ:	Describe standards of professional practice for critical care nursing.
TOP:	Nursing Process Step: Implementation		
MSC:	NCLEX Client Needs Category: Safe and Effective Care Environment