ICU SKILLS ASSESSMENT EXAM

1. Mr. Baker is starting out on a low dose level of dopamine hydrochloride (Intropin)
intravenously. Which of the
following can the nurse expect?
A) A decrease in glomerular filtration rate.
B) A decrease in the force of myocardial contractions
C) An increase in urine output
D) An increase in tactile sensations

2. An adult woman is admitted with metabolic acidosis. Which set of arterial blood gasses
should the nurse expect to find in a client with metabolic acidosis?
A) pH 7.28; PCO2 – 55; HCO3 – 26
B) pH 7.50; PCO2 – 40; HCO3 – 31
C) pH 7.48; PCO2 – 30; HCO3 – 22
D) pH 7.30; PCO2 – 36; HCO3 – 18

3. The nurse is caring for an adult admitted to the coronary unit with a myocardial
infarction. During the second night in the CCU, the client develops congestive heart failure.
A Swan-Ganz catheter is inserted to monitor the client for left
ventricular function because:
A) it provides information about pulmonary resistance
B) it measures myocardial oxygen consumption
C) it controls renal blood flow
D) it controls afterload

4. The nurse enters the room of a client who has a chest tube attached to a water seal
drainage system and notices the chest tube is dislodged from the chest. The most
appropriate nursing intervention is to:
A) notify the physician
B) insert a new chest tube
C) cover the insertion site with petroleum gauze
D) instruct the client to breath deeply until help arrives

5. The nurse is caring for a person who is admitted in acute renal failure. The appearance of
the U wave on the ECG should alert the nurse to check laboratory values for:
A) hyperkalemia
B) hypokalemia
C) hypernatremia
D) hyponatremia

6. An adult male client is admitted with a diagnosis of acute M.I. (myocardial infarct). He is
attached to a cardiac monitor and has an IV catheter in place. His cardiac rhythm has been
normal sinus rhythm with occasional PVC’s. The nurse notes a sudden change on the
cardiac monitor screen to a very irregular, chaotic-looking pattern. The client appears to be
sleeping. The most appropriate action on the part of the nurse is to:
A) administer precordial thump
B) obtain the defibrillator
C) begin cardiopulmonary resuscitation
D) check the client’s ECG electrodes

7. A client in the intensive care unit is on a volume-cycled mechanical ventilator. The high-
pressure alarm (PAP) begins to sound repeatedly. The client is sleeping quietly. What is the
most appropriate initial response by the nurse?
A) Call the respiratory therapist to check the ventilator
B) Turn the client to stimulate coughing
C) Obtain arterial blood for blood gas analysis
D) Check the ventilator tubing

8. A client has a closed head injury. Vital signs are T 103°F rectally; pulse 100; respirations
24; BP 110/84. Hourly urine output is 200 ml/hr. What is the best understanding of the
cause of these findings?
A) Damage to the hypothalamus resulting in decreased hormone production
B) Movement of fluid from the tissue into the intravascular space, resulting from sepsis.
C) An increase in antidiuretic hormone (ADH) as a result of injury to the hypothalamus
D) Fluid shifts from the tissue into the intravascular space due to administration of normal
saline used during
fluid resuscitation.

9. An adult is admitted with early left-sided congestive failure. Which symptom should the
nurse expect to find?
A) Bradycardia
B) Rales
C) Liver engorgement
D) Jugular vein distention

10. Which serum potassium level reported for an adult requires no immediate nursing
intervention?
A) 3.2 mEq/liter
B) 4.0 mEq/liter
C) 5.7 mEq/liter
D) 6.0 mEq/liter

11. Two days after admission with deep vein thrombosis, an adult client develops a cough
with slight hemoptysis and complains of shortness of breath and sharp pain under his right
shoulder blade. A pulmonary embolus is suspected and a ventilation/perfusion scan of the
lungs is ordered. The ventilation/perfusion scan of a client with pulmonary
embolism who has no other pulmonary disease demonstrates:
A) decreased ventilation; decreased perfusion
B) decreased ventilation; normal perfusion
C) normal ventilation; decreased perfusion
D) normal ventilation; normal perfusion

12. The nurse is administering CPR. Which is most important for the nurse to evaluate to
determine whether the procedure is being done effectively?
A) Feeling the carotid pulse during compressions.
B) Observing the chest rise and fall during rescue breathing
C) Monitoring arterial blood gasses.
D) Monitoring the electrocardiogram rhythm

13. The physician has ordered total parenteral nutrition to be delivered through the central
venous line of an adult admitted to the medical intensive care unit. When changing the
tubing to institute the TPN, the nurse should perform which of the following activities to
prevent the occurrence of an air embolism?
A) Cleanse the central line insertion site with povidone-iodine ointment
B) Wrap sterile Vaseline gauze around the hub of the open central venous line while
priming the TPN line.
C) Clamp the central venous line while connecting the primed TPN administration set.
D) Place an alcohol wipe over the open end of the central venous catheter while preparing
to insert the primed
TPN tubing.

14. Mr. Y. is admitted to the medical unit with symptoms of angina. Nitroglycerin is
administered. Which assessment indicates the client is responding positively to the
administration of nitroglycerin?
A) The client’s blood pressure drops
B) Mr. Y. reports he has developed a headache.
C) Mr. Y. asks to be discharged because his pain is relieved.
D) Mr. Y. reports he has developed nausea

15. An adult is receiving a transfusion of whole blood. The client has undergone head
trauma and is unconscious. The nurse assesses the client and finds a week pulse, fever, and
hypotension. The best initial action by the nurse is:
A) notify the physician
B) stop the blood transfusion
C) recheck the vital signs
D) check the amount of urine output

16. When administering TPN, the nurse makes sure the:

A) IV site is kept aseptic while infusing the solution
B) Feeding is poured into a pouch and then infused
C) Solution is only hung for a maximum of eight hours at a time
D) New formula is added to the partially used solution so the line does not run dry

17. Ms. A.’s blood gas results are: pH7.31, PaCO2 49, and HCO3 24. The nurse interprets this
as:
A) respiratory acidosis
B) respiratory alkalosis
C) metabolic acidosis
D) metabolic alkalosis

18. An adult has a Hickman type central venous catheter and needs to have blood drawn
from it. Which of the following is the nurse going to do first?
A) Use sterile technique to assemble the supplies needed
B) Aspirate and discard the first 5 ml of the blood
C) Flush the catheter with normal saline according to hospital policy
D) Remove the cap on the catheter and replace it with a new one

19. A nurse is obtaining a Glasgow Coma Score on a client. The score is as follows: Best eye
opening – 3, Best motor
response – 6, Best verbal response – 4
A) opens eyes to speech, obeys verbal commands, and is confused
B) Opens eyes to pain, decoricates to pain, and does not speak
C) Opens eyes to pain, no motor response, and has inappropriate speech
D) Opens eyes spontaneously, obeys verbal commands, and is oriented x 3

20. A client is admitted post craniotomy. Decadron 4 mg IV is ordered every six hours. The
nurse understands the Decadron is ordered to:
A) stabilize the blood sugar
B) decrease cerebral edema
C) prevent seizures
D) maintain the integrity of the gastric mucosa

21. A woman who is receiving tamoxifen (Tamofen) 20 mg po bid asks the nurse why she is
receiving this medication and what side effects are possible. The best response for the
nurse to make is:
A) “Tamoxifen is a vasodilator-antihypertensive. It will lower your blood pressure. The
main side effects include
dizziness, headache, nasal congestion, and nausea.”
B) “Tamoxifen will help you manage your nausea and vomiting associated with
chemotherapy. It may cause
you to be a little sleepy and constipated, and to have dry eyes.”
C) “Tamoxifen is used to treat your breast cancer. It will help stop the tumor from growing.
You may have some
nausea, vomiting, and hot flashes from this drug.”
D) “Tamoxifen is an antiulcer medication. Constipation is the major side effect.”

22. The nurse is planning care for an adult client who is receiving chemotherapy for cancer.
Which side effect should the nurse anticipate because it is the most common for clients
receiving cancer chemotherapy?
A) Nausea and vomiting
B) Cardiac arrhythmias
C) Paralytic ileus
D) Diuresis

23. A young man is admitted in chronic renal failure and placed on hemodialysis three
times a week. Which is an attainable short- term goal for this person when he is placed on
hemodialysis?
A) Understanding the treatment and its implications
B) Independence in the care of the AV shunt
C) Self-monitoring during dialysis
D) Recording dialysate composition and temperature

24. The nurse is caring for a woman who is on hemodialysis. She has an arteriovenous
fistula. Which finding is expected when assessing the fistula?
A) Ecchymotic area
B) Enlarged veins
C) Pulselessness
D) Redness

25. The nurse is assessing a client following hemodialysis. Which of the following findings
indicates the treatment was effective?
A) Hypertension
B) Hyperkalemia
C) Fluid volume decrease
D) Cardiac dysrhythmias