1. What are appropriate nursing interventions for the patient with delirium in the ICU?

(Select
all that apply)
A. Use clocks and calendars to maintain orientation.
B. Encourage round-the-clock presence of caregivers at the bedside.
C. Sedate the patient with appropriate drugs to protect the patient from harmful
behaviors.
D. Silence all alarms, reduce overhead paging, and avoid conversations around the patient.
E. Identify physiological factors that may be contributing to the patient's confusion and
irritability.

Rationale: The use of clocks and calendars can help orient the patient with delirium in the
intensive care unit (ICU). If the patient demonstrates hyperactivity, insomnia, or delusions,
management with neuroleptic drugs (e.g., haloperidol [Haldol]) can be considered. Physical
conditions such as hemodynamic instability, hypoxemia, hypercarbia, electrolyte disturbances,
and severe infections can precipitate delirium.

2. You have just received change of shift report. Which patient should you assess first?
A. 62 year-old man who is scheduled for a cardiac cath, and is ready to be transported now
B. 58 year-old woman with COPD with an O2 saturation of 92% on 2 liters of O2, who is
scheduled to be discharged home on O2
C. 36 year-old man admitted with an exacerbation of asthma with RR 36 at rest, and
whose wheezing has diminished
D. 72 year-old woman with history of asthma with HR 90 and is due for her beta-blocker

Rationale: RR 36 and diminished wheezing indicative of respiratory distress and needs prompt
attention

3. You are about to handover patient care to your on-coming nurse colleague. Which patient
requires the most immediate attention?
A. 62 year-old man with COPD who has just completed his scheduled bronchodilator
B. 68 year-old woman with type 2 diabetes who had CVA 2 days ago
C. 72 year-old woman with history of asthma with HR 90 and is due for her beta-blocker
D. 48 year-old man admitted with cellulitis of his right hand after a construction accident,
currently on IV antibiotics, with a temperature of 101.8

Rationale: Cellulitis is serious infection, involving swelling of subcutaneous tissue, fluid

displacement due to 3rd spacing. What else would you assess?