1.

A nurse caring for patients in a critical care unit knows that providing good oral hygiene is
an essential part of nursing care. What are some of the benefits of providing this care?
Select all that apply.
A. It promotes the patient sense of well-being.
B. It prevents deterioration of the oral cavity.
C. It contributes to decreased incidence of aspiration pneumonia.
D. It eliminates the need for flossing.
E. It decreases oropharyngeal secretions
F. It compensates for an inadequate diet.

Rationale: Adequate oral hygiene is essential for promoting the patient's sense of well-being
and preventing deterioration of the oral cavity. Diligent oral hygiene care can also improve oral
health and limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence
of aspiration pneumonia and other systemic diseases. Oral care does not eliminate the need for
flossing, decrease oropharyngeal secretions, or compensate for poor nutrition.

2. An older adult patient has a complication after a cardiac catheterization and has to remain
in the intensive care unit (ICU) for an extra three days. For what is the patient most at risk?
A. Delirium
B. Depression
C. Alcohol withdrawal
D. Aggressive behaviors

Rationale: Older adult patients who spend prolonged amounts of time in the ICU are at risk for
delirium caused by ICU psychosis. Aggressive behaviors and depression can also be parts of ICU
psychosis, but this disorder is most often characterized by delirium. There is not enough
information in this scenario to determine if the patient is at risk for alcohol withdrawal.

3. A client receiving a transfusion of packed red blood cells begins to vomit. The client's blood
pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is
100.8 ° F orally from a baseline of 99.2 ° F. The nurse determines that the client may be
experiencing which complication of a blood transfusion?
A. Septicemia
B. Hyperkalemia
C. Circulatory overload
D. Delayed transfusion reaction

Rationale: Occurs with the transfusion of blood contaminated with microorganisms. Signs
include chills, fever, vomiting, diarrhea, hypotension, and the development of shock.