ICU REGISTERED NURSE CALIFORNIA CORRECTIONAL EMPLOYMENT APPLICATION PACKET Welcome to Star Nursing your Nurse Registry that is owned and operated by Regist

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ICU REGISTERED NURSE CALIFORNIA CORRECTIONAL EMPLOYMENT APPLICATION PACKET Welcome to Star Nursing your Nurse Registry that is owned and operated by Regist Powered By Docstoc
					                             ICU REGISTERED NURSE
             CALIFORNIA CORRECTIONAL EMPLOYMENT APPLICATION PACKET
Welcome to Star Nursing, your Nurse Registry that is owned and operated by Registered Nurses. We
specialize in offering the finest, most experienced nurses for staffing support throughout the United
States with multiple needs in Arizona, California, Florida, Louisiana, and Texas.

Please use this letter as your checklist for your application. Star Nursing staffs multiple health care
facilities and Correctional locations. Since you have expressed and interest in working at Correctional
Facilities, please provide all the completed forms in the Application Forms table and copies of all the
required current documents. You may tab though this Application Packet and type to complete the
forms. When complete return via email to your recruiter at name@starnursing.com or email to
recruiter@starnursing.com.

                                           APPLICATION FORMS
    Employment Application
    Application Employment Verification
    State Tax Form
    Employment Eligibility Verification (I-9 form)
    Tax Home (if Traveling Nurse)
    Notification and Release Form
    Paycheck Automatic Withdrawals and Deposits
    Medical Release Agreement
    Registered Nurse Job Description
    ICU Skills and Test
    Rhythms Test

                                  REQUIRED CURRENT DOCUMENT COPIES
    Resume
    Driver’s License
    Social Security Card or other I-9 documentation
    Nursing License (for each state)
    CPR/BLS
    TB or Radiology report (within 1 month for skin or 90 days for chest)



Once we have received your application and complete our verification, we will actively seek an
assignment that matches your background and qualifications. Please do not hesitate to call with any
questions or concerns you may have. For Correctional Facilities you will also be receiving paperwork
for gate clearance separately. You must be gate cleared in order to be offered a position at the
Correctional Facility and you will be required to attend an orientation at the Correctional Facility that
may be from one week to three weeks long.


                                               WELCOME ABOARD!



                                        CA Correctional RN ICU Employment Application Packet v-3 121007            Page 1 of 23
 5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                   Tel: 877.687.7399            Fax: 877.687.7400
                                                                        Employment Application
                                                                                         Personal
  Name:               ,                                                                                                                            SSN:
                                   Last                                                    First                                   Initial
  DOB:                                 Address:                                                                                       ,
                M/D/YY                                                   Street & Number                                          City                         State           Zip Code
  Phone Numbers:
                                            Home                                                           Cell                                                        Fax
  Email:                                                                                                                            Preferred Contact Method:

  Emergency contact name and phone number:
                                                                                             Name                                                               Number
  Have you ever been convicted of a felony or misdemeanor?                                    yes          no Drivers License#:                                               Exp.
  How were you referred to us?                                                                     Please enter Employee referral name:
                                                                                        Preferences
  Facility Preference:             Hospital            Correctional           Employment Type:                    Traveler        Per Diem                Full Time            Part Time
  Available Shifts:           Days            Evenings              Nights                  Preferred Shift Hours            8               12                  Start Date:
  Preferred Location:
                                                                                        Specialties
     ER           ICU           NICU          PACU              PICU         Pediatric             Psychiatry          SUV           TCU              Telemetry              Med/Surg

     Maternal/Nursery                  NP     Perioperative                  CNA                   LVN/LPN             {other}       {other}
                                                                                         Licenses
                                          Professional Licenser                                                      Professional License Type                 Exp. Date              State




  Pertinent Certifications/Licenses:
  CPR           , ACLS
         Ex p. Date       Ex p. Date               Ex p. Date             Ex p. Date                    Ex p. Date                 Ex p. Date                   Ex p. Date             Ex p. Date


                                                                                        Education
                                                                                                                                                                                 Degree
    School Type                    Name of School                                      Location                                  Major             # of Yrs.       Degree
                                                                                                                                                                                  Date
  High School
  Junior College




                                                                CA Correctional RN ICU Employment Application Packet v-3 121007                                        Page 2 of 23
5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                                            Tel: 877.687.7399                            Fax: 877.687.7400
                                                              Employment History
  May we contact your employer?        yes          no             Employer:
  Facility:                                                 Address:                                               Phone:
  Unit:                                                         Dates of Employment:                -         Salary:
  Reason for Leaving:                                                                              Name of Supervisor:
  May we contact your employer?        yes          no             Employer:
  Facility:                                                 Address:                                                    Phone:
  Unit:                                                         Dates of Employment:                 -        Salary:
  Reason for Leaving:                                                                              Name of Supervisor:
  May we contact your employer?        yes          no             Employer:
  Facility:                                                 Address:                                               Phone:
  Unit:                                                         Dates of Employment:                -         Salary:
  Reason for Leaving:                                                                              Name of Supervisor:
  May we contact your employer?        yes          no              Employer:
  Facility:                                                 Address:                                               Phone:
  Unit:                                                         Dates of Employment:                -         Salary:
  Reason for Leaving:                                                                              Name of Supervisor:
  May we contact your employer?        yes          no             Employer:
  Facility:                                                 Address:                                                   Phone:
  Unit:                                                         Dates of Employment:                 -             Salary:
  Reason for Leaving:                                                                              Name of Supervisor:
  May we contact your employer?        yes          no             Employer:
  Facility:                                                 Address:                                               Phone:
  Unit:                                                         Dates of Employment:                -         Salary:
  Reason for Leaving:                                                                              Name of Supervisor:

  I hereby certify that the information contained in this application is true and correct to the best of my knowledge, and authorization the
  company to verify any of the statements or information provided herein, unless I have indicated to the contrary. I also authorize the company
  to review any credit reports, Department of M otor Vehicles records and criminal records concerning me. I further authorize the reference
  listed above, as well as current and prior employers and agencies that may have information concerning me to provide the company any and
  all of such information and any other pertinent information that they may have. I understand that any m isrepresentation or falsification, or
  material om ission of information on this application may result in my failure to receive an offer or, if hired, my dismissal from employment.
  Furthermore, I authorize Star Nursing to utilize all submitted employment documentation to be used for position placement with Star Nursing’s
  clients, subsidiaries, customers, affiliates, and government agencies (“Entity”) and agree that Star Nursing is fully respons ible for all
  documentation in their possession and upon release to an Entity, those documents are furthermore the responsibility of that entity to ensure
  appropriate confidentiality and I release Star Nursing of any and all liability for said documents.

  Signature:                                                                                                                         Date:
      I                                                   agree that I am submitting this and other documents electronically and have typed
      my name above and dated in the Signature Space in lieu of an original signature and hereby authorize Star Nursing and its affiliates to
      utilized the submitted documents for the purposes noted on this release and on other Star Nursing documents.


                                               CA Correctional RN ICU Employment Application Packet v-3 121007                   Page 3 of 23
5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                   Tel: 877.687.7399                    Fax: 877.687.7400
                                STATE TAX F ORMS AND I-9 F ORM


  Please copy and past the links into your web browser to get the forms that you need to fill out.
  We only require the form for the State that you are interested in working in.


  California State Tax Form - W-4:              http://www.irs.gov/pub/irs-pdf/fw4.pdf

  Arizona State Tax Form - A-4:                 http://www.azdor.gov/ADOR_Forms/90-99/91-0041.pdf

  Louisiana State Tax Form - L-1:               http://www.rev.state.la.us/forms/taxforms/1300(4_01)f.pdf


  All employees must complete an I-9 Form.

  I-9 Form:                                     http://www.uscis.gov/files/form/i-9.pdf

  If you would like to sign any of these forms electronically, please complete the below:


                        ELECTRONIC SIGNATURE SUBMITTAL AGREEMENT
         I                                                  agree that I am submitting the following forms:

                           Employment Eligibility Verification Form (I-9)

                           Arizona State Tax Form A-4

                           Louisiana State Tax Form L-1

                           California State Tax Form W-4

         electronically and have typed my name in the Signature Space on the form in lieu of an
         original signature and hereby authorize Star Nursing and its affiliates to utilized the
         submitted documents for the purposes noted on the submitted form.

         As such I am also electronically signing and dating this form that will be placed with the
         said documents above as proof of my agreement to this/these electronic signature(s).

         Signature:                                                                               Date:




                                     CA Correctional RN ICU Employment Application Packet v-3 121007             Page 4 of 23

5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                   Tel: 877.687.7399             Fax: 877.687.7400
                                          APPLICANT EMPLOYMENT VERIFICATION
   Applicant, Please Complete:

   Former Employer Information

       Facility:

       Address:
                     #           Street


                                                     City                                    State                  Zip Code
       Phone #:                                              Supervisor:

       Dates of Employment:                   From:                                            To:

       Unit:                                                         Title:
   I herby authorize any individual, hospital or company with whom I have been associated to furnish any information
   concerning my employability and do herby release the individual, hospital or company from all liability for any
   damages whatsoever incurred in furnishing such information. By typing your name below you agree to the above
   and are authorizing submission of your application employment verification electronically, otherwise please sign
   and return the Application Employment Verification by email (scan), fax or mail (original).

                    Print Name                                                   Signature                                     Date



   Employer Please Complete:

   Was the applicant employed by you?                       yes       no Position:

   Dates of Employment: From:                                To:              Would you re-employ this applicant?              yes          no

   If no, why?

     Please rate applicant in the following category:
                                                                     Excellent               Good            Fair          Weak
      Knowledge of work
      Quality of work
      Professional appearance
      Attitude
      Character
      Leadership
      Attendance
   Comments:



                   Name of person making reference                                                   Title                       Date


                                          Thank You for Taking Time to Fill Out this Form
                                            CA Correctional RN ICU Employment Application Packet v-3 121007                           Page 5 of 23

5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                               Tel: 877.687.7399                 Fax: 877.687.7400
                                              APPLICANT EMPLOYMENT VERIFICATION
      Applicant, Please Complete:

      Former Employer Information

           Facility:

           Address:
                         #           Street


                                                         City                                    State                  Zip Code
           Phone #:                                              Supervisor:

           Dates of Employment:                     From:                                          To:

           Unit:                                                         Title:

      I herby authorize any individual, hospital or company with whom I have been associated to furnish any information
      concerning my employability and do herby release the individual, hospital or company from all liability for any
      damages whatsoever incurred in furnishing such information. By typing your name below you agree to the above
      and are authorizing submission of your application employment verification electronically, otherwise please sign
      and return the Application Employment Verification by email (scan), fax or mail (original).

                        Print Name                                                   Signature                                     Date



      Employer Please Complete:

      Was the applicant employed by you?                        yes       no Position:

      Dates of Employment: From:                                 To:              Would you re-employ this applicant?              yes        no
      If no, why?

         Please rate applicant in the following category:
                                                                         Excellent               Good            Fair          Weak
          Knowledge of work
          Quality of work
          Professional appearance
          Attitude
          Character
          Leadership
          Attendance
      Comments:



                       Name of person making reference                                                   Title                       Date


                                              Thank You for Taking Time to Fill Out this Form.
                                              CA Correctional RN ICU Employment Application Packet v-3 121007                      Page 6 of 23

5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                              Tel: 877.687.7399                  Fax: 877.687.7400
                       PERMANENT TAX HOME NOTIFICATION
  Last Name:                                                        First Name:
  Social Security Number
  The IRS requires that you pay taxes on travel expense reimbursement and housing benefits unless you are
  maintaining a residence while on assignment with us. This form w ill provide us with the necessary
  information about your tax home.

  If you do not return this completed form to us or if you do not meet the “tax home” criteria, the
  IRS requires that we treat travel and housing benefits as income, and we will withhold taxes
  accordingly.
  You should consult your tax advisor regarding your permanent tax residence and tax liability of travel
  and housing benefits.
  The IRS criteria used to determine whether you are maintaining a permanent residence is outlined below:
      1. There must be a realistic expectation that you will return to and live at your home and your tax
          home must be distinct and separate from your temporary residence
      2. You are paying to maintain your permanent tax residence while you are on assignment (ie rent,
          mortgage, room and board)
      3. Generally you must meet at least one of the following criteria:
               a. You lived at your permanent tax residence immediately prior to your current
                   employment, or
               b. You have either a family member utilizing the residence, or you utilize the residence
                   frequently for purpose of your own lodging.
  The permanent tax residence must be your habitable living quarters and should be at least 50 miles away
  from your temporary residence. Payments to maintain your personal tax residence must be real and
  substantial.

  The IRS considers employment away from home in a single location that exceeds or may exceed one
  year, to be indefinite, not temporary. Under these conditions, housing and travel benefits would be
  subject to withholding.
                        Please complete the fields below and return with your contract.
  Do you have a Permanent Tax Home as defined above?                    yes         no If yes, please list the address
  below.
  Address:                                           City:                              State:          Zip:
  I certify that the above statements are true to the best of my knowledge and I agree to notify Star Nursing
  Agency in writing if any of the above conditions change. I acknowledge that I have been advised to
  consult with a tax advisor in completing this form.
  Furthermore I understand that false representation made on the form may subject me to additional taxes,
  penalties and interest payable to the IRS for which I agree to take full responsibility.

  Signature:                                                                            Date:
      I                                          agree that I am submitting this document electronically
      and have typed my name in the Signature Line above in lieu of an original signature and dated
      above and hereby authorize Star Nursing and its affiliates to utilize this submitted document.

                                     CA Correctional RN ICU Employment Application Packet v-3 121007            Page 7 of 23

5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                     Tel: 877.687.7399          Fax: 877.687.7400
                                                        Notification and Release
  The information contained in my application for employ ment with Star Nursing, is true to t he best of my knowledge and belief. I
  understand that any misrepresentation or false statement made by me in connections with the application or any related docume nts
  which is deemed material by Star Nursing, shall result in Star Nursing not employing me or, if employed, terminating my
  emp loyment. I understand and agree that all information furnished in my application and all attachments may be verified by S tar
  Nursing, or its authorized representative. I hereby authorize all individuals and organizations named or referred to in my applicat ion
  and any law enforcement organizat ion to give Star Nursing, all information relative to such verification and hereby release such
  individuals, organizations, and Star Nursing from any and all liab ility for any claim or damage resulting there from. I hereby
  acknowledge that I have been informed by Star Nursing, that Star Nursing may seek to obtain a consumer report and/or investigative
  report that will include personal information regarding me, including but not limit ed to: education history, work references, driving
  records and criminal h istory or criminal arrest records if allowed, in order to assist Star Nursing, in making certain employ ment
  decisions. I further acknowledge notification by Star Nursing, that reports may be provided to Star Nursing by other firms
  subcontracted for that purpose. I, my heirs, assigns and legal representatives, hereby release and fully discharge Star Nurs ing its
  parents and affiliated companies and the respective officers, directors, shareholders, employees, agents of each, including
  subcontractors from any and all claims, monetary or otherwise, that I may have against St ar Nursing, its parents, affiliates or
  subcontractors, arising out of the making, or use of, either a consumer report and/or investigative report, including any errors or
  omissions contained or omitted fro m such reports or investigations. Star Nursing agrees to inform you if an employ ment decis ion has
  been influenced by informat ion contained in a consumer report. Make all requests in writing to Caro lina Information P.O. Box 127,
  Wake Forest, NC 27588, or call 919-570-9861 to obtain a free copy of your report.

      List all names that you have used during the last seven (7) years (including married, maiden, and aliases). Please type or print:

  Name:                                                                                                    Date of Birth:
             First   Middle   Last

  Maiden Name:                                                                                             Date Last Used:

  Aliases:                           Dates Used:         -               Aliases:                                  Dates Used:          -

  Social Security Nu mber:                          Driver License Nu mber:                            State:            Exp . Date:

  Current and Previ ous Address (List a mini mum of seven years):
  Start Date End Date
                                     Address                      City                  State                   County                      Country
    (m/y)      (m/y)




  Applicant:                                                                                                             Date:
                                        Signature
      I                                          agree that I am submitting this and other documents electronically and have typed my
      name in the signature line above and dated in lieu of an original signature and hereby authorize Star Nursing and its affiliates
      to utilize the submitted documents for the purposes noted on this release and on other Star Nu rsing documents.
                                                          Star Nu rsing Use Only
                    Fax to OccuTest: 919-861-0803 or call 919-861-0801 to speak with a customer service representative
    Federal Criminal Nationwide                                           Education Verification
    Statewide Criminal Search                                             Employ ment Verificat ion
    Statewide Civil Search                                                DOT Emp loy ment Verification
    Credit Report                                                         Motor Vehicle Records
    Social Security Nu mber Verification                                  Corporate Cred it Checks


                                     CA Correctional RN ICU Employment Application Packet v-3 121007                                    Page 8 of 23

5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                                Tel: 877.687.7399                       Fax: 877.687.7400
                                AUTHORIZATION AGREEMENT
                         FOR AUTOMATIC WITHDRAWALS AND DEPOSITS


  I hereby authorize Star Nursing Inc., to initiate credit entries and, if necessary, adjust ment for
  any credit entries made in error to my account indicated below and with the bank named below:

  Bank Name:

  Address:

  City:                                                     State:                      Zip:

                    Choose One (Transit/ABA Number – lowe r left corner of check)

  Checking Account No. :

  Saving Account No. :

  This authority is to remain in full force and effect until Star Nursing Inc. has received written
  notification from me of its termination in such time and in such manner as to afford Star Nursing
  Inc., and the Bank a reasonable opportunity to act on it.

  Authorized Signature:                                                                         Date:

           I                                   agree that I am submitting this document
           electronically and have typed my name in the signature line above in lieu of an
           original signature and dated above and hereby authorize Star Nursing and its affiliates
           to utilize this submitted document.

                                        Place Voided Check Below:




                                     CA Correctional RN ICU Employment Application Packet v-3 121007           Page 9 of 23

5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                   Tel: 877.687.7399           Fax: 877.687.7400
                            MEDICAL RELEASE
                      HEALTH INFORMATION D ISCLOSURE


  I hereby authorize Star Nursing Agency, Inc. to disclose any and all
  health screening to Medical Facilities within the USA; for purpose
  of regulatory document management of Agency personnel.




  Employee Name:                                                                             Date:



  Signature:



  Star Nursing Rep:                                                                          Date:



           I [enter full name] agree that I am submitting this document electronically and have typed
           my name above in lieu of an original signature and hereby authorize Star Nursing a nd its
           affiliates to utilize this submitted document.




                                     CA Correctional RN ICU Employment Application Packet v-3 121007         Page 10 of 23

5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                   Tel: 877.687.7399          Fax: 877.687.7400
                            REGISTERED N URSE JOB D ESCRIPTION


  Education and Experience Require ments

  Must have graduated from an accredited school of nursing, hold a current state license within the
  state you are practicing in and have a minimum of two years of clinical experience within a
  hospital setting.

  Position Summary

  Registered Nurse will be under the general direction of the Director of Nursing and direct
  direction of any Charge Nurses as identified by the facility in which the nurse is placed. The
  Registered Nurse is responsible for professional nursing care and related assistance to patients on
  the unit where assigned. Provides direction to the Licensed Practical Nurses and non
  professional nursing personnel in providing direct patient care. The Registered Nurse supports
  the medical care of patients under direction of the Medical Staff pursuant to the objectives of the
  hospital and in compliance with the Nurse Practice Act in the state of practice.

  Agency Nurses are expected to display knowledge and skills necessary to provide care from
  admission to discharge of patients or clients in the home care setting or any other health care
  facility.

  The above statements are intended to describe the general nature and level of work to be
  performed by the persons assigned to this classification. They are not to be construed as an
  exhaustive list of all job duties performed by the professional.




                                           Name (Print)




                                             Signature                                                   Date


      I [enter full name]                           agree that I am submitting this document electronically and have
      typed my name and dated above in lieu of an original signature and hereby authorize Star Nursing and its
      affiliates to utilize the submitted document.




                                CA Correctional RN ICU Employment Application Packet v-3 121007            Page 11 of 23

5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                   Tel: 877.687.7399        Fax: 877.687.7400
Name:                                                                                        Date:
No. of years of experience:                        Specialty Area:              /      /      /
Certifications: BLS exp.                           ACLS exp.                        CCRN exp.                         exp.


                                                         ICU SKILLS
                                             No       <2      >2                                                No      <2      >2
                                            Exp.     Yrs.    Yrs.                                              Exp.    Yrs.    Yrs.
Cardi ovascular                                                       Cardi ovascular (cont.)
 Assessment:                                                           Care of patients (cont.):
     Circulat ion checks                                                  Heart Transplant
     Heart sounds                                                         IABP
 Interpretation of:                                                       Liver Failure
     12 lead EKG interpretation                                           MI
     Arrhythmia interpretation                                            Post open heart
     Arterial pressure interpretation                                     Post-op abdominal ex
     Card iac enzy mes                                                    Post thoracic surgery
     Coagulation labs                                                     Renal Failure
     CVP                                                                  Sepsis
     MAP                                                                  Stent placement
     PCW                                                               Cardiac Med ications:
     SGC interpretation                                                   Amiodarone
     SVO2                                                                 Atropine
 Equip ment:                                                              Doburamine
     12 lead p lacement                                                   Dopamine
     Bedside monitor                                                      Ep inehrine
     Defibrillator                                                        Es molol
     External pacer                                                       Inocor.
     Lead placement                                                       Nipride
     Pericardial window d rain                                            Nitrog lycerine
 Procedures:                                                              TPA
     Arterial Line insertion                                              Vasopressin
     Card ioversion                                                   Neurological
     CT insertion                                                      Assessment:
     IABP insertion                                                       Cran ial nerves
     Pericardiocentesis                                                   Glasgow co ma scale
     SGC insertion                                                        Level of consciousness
     Temporary pacer insertion                                            Motor deficits
 Care of patients:                                                     Equip ment:
     AAA repair                                                           Halo tract ion
     Angiogram                                                            Intracranial pressure monitoring
     Angioplasty                                                          Lu mbar drains
     Card iac arrest                                                      Nerve stimulators
     Card iac Tamponade                                                   Rotating bed
     CHF                                                                  Stryker frame
     DIC                                                                  Use of hyper/hypothermia b lankets

                                        CA Correctional RN ICU Employment Application Packet v-3 121007                  Page 12 of 23

 5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                             Tel: 877.687.7399          Fax: 877.687.7400
                                              No       <2      >2                                                  No      <2       >2
                                             Exp.     Yrs.    Yrs.                                                Exp.    Yrs.     Yrs.
Neurological (cont.)                                                   Pulmonary (cont.)
 Equip ment (cont.)                                                     Procedures (cont.):
    Ventriculostomy                                                         Assist with thoracentesis
 Care of Patients:                                                          Chest tube insertion
    Aneurysm precautions                                                    Emergency tracheostomy
    Basal skull fracture                                                    Extubation
    Closed head trauma                                                      NG suctioning
    Co ma                                                                   OETT suctioning
    CVA                                                                     Tracheostomy suctioning
    Encephalit is                                                           Ventilator weaning
    Laminectomy                                                         Care of patients:
    Meningitis                                                              Acute pneumonia
    Post craniotomy                                                         ARDS
    Post-op aneurysm clipping                                               Aspiration pneumonia
    Spinal cord in jury                                                     Chest trauma
    Tumor resection                                                         COPD
    VP shunts                                                               Cor pulmonale
Nursing Skills                                                              Fresh tracheostomy
    Charge Nu rse Role                                                      Lung CA
    Conscious Sedation                                                      Lung surgery
    CVVD                                                                    Lung transplant
    CVVH                                                                    PE
    Drug Calcu lations                                                      Status asthmaticus
    Ep idural analgesia, PCA pu mps                                         Tuberculosis
    ETOH/DT management                                                  Medications:
    Post-Op Recovery                                                        Theophylline
Pulmonary                                                              Specialty
 Assessment:                                                                Burn Unit
    ABG Interpretation                                                      Card iac Care Unit
    Breath sounds                                                           Medical ICU
    Respiratory distress                                                    Neuro ICU
 Equip ment:                                                                Surgical ICU
    Ambu bags                                                               Transplant Unit
    BIPAP mach ines                                                         Trau ma
    Chest tubes                                                        Please list any additional ICU s pecialties or skills not
    Nasal Cannula                                                      yet covered and your clinical years of experience.
    Non-rebreather mask                                                                                                       years
    Pulse o ximetry                                                                                                           years
    Simp le mask                                                                                                              years
    Tracheostomy                                                                                                              years
    Ventilators                                                                                                               years
 Procedures:                                                                                                                  years
    Arterial stick for A BG's                                                                                                 years
    Aspirate blood fro m Arterial line                                                                                        years
    Assistance with intubation                                                                                                years
    Assist with Bronchosopy                                                                                                   years
                                         CA Correctional RN ICU Employment Application Packet v-3 121007                    Page 13 of 23

 5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                              Tel: 877.687.7399             Fax: 877.687.7400
                                                    ICU TEST
Name:                                                                                Date:

Please mark your answer to the following questions, this form may be tabbed through or use a
mouse to click into the box and mark each answer. Each question has only one correct answer.

1.    A Client with a severe head trauma is monitored for Cushing's triad, which results when
      pressure is exerted on the brain stem by intracranial hypertension or erniation syndrome.
      What are the three signs of Cushing's Triad?
             (A) Increased blood pressure with widening pulse pressure, brdycardia, and abnormal
                 respiratory pattern
             (B) Hypertension, seizures, and cluster breathing pattern
             (C) Pinpoint pupils, unilateral paresthesias, and Wernicke’s aphasia
             (D) Contralateral loss of vision in the same side of each eye, diplopia, and loss of
                 contralateral sensation

2.    A 56-year-old man is scheduled for bypass, surgery. His critical care nurse notes that his
      platelet count is 28,000/mm3. Which of the following is the best course of action for this
      nurse to take?
             (A) Complete the preoperative checklist and administer the preoperative medication as
                 prescribed
             (B) Call the laboratory to have the complete blood count redone
             (C) Delay preoperative preparations and call the physician
             (D) Check the client’s blood pressure, heart rate, and respiratory status

3.    A patient has just been intubated. The nurse ausculates his lung after intubation and notes
      normal breath sounds on the right side and diminished breath sounds on the left side. What is
      the best action for the nurse to take?
             (A)    Increase the tidal volume on the ventilator
             (B)    Pull the endotrachael tube back 1 inch
             (C)    Suction the patient to remove the mucus plug
             (D)    Leave the tube alone because this is a normal finding

4.    A patient has been taking quinidine for an arrhythmia. Which of the following would indicate
      that the patient is experiencing quinidine toxicity?
             (A)    Frequent diarrhea
             (B)    Slow, irregular pulse
             (C)    Tinnitus and skin rash
             (D)    Widening QRS complex



                                     CA Correctional RN ICU Employment Application Packet v-3 121007             Page 14 of 23

5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                              Tel: 877.687.7399   Fax: 877.687.7400
5.       A patient is admitted into the ICU with a temperature of 105.6F. In reviewing the laboratory
         data, the nurse notices a leukocyte shift to the left, evidenced by an increased number of
         immature neutrophilis. This is an indication of which condition?
                (A)    Anemia
                (B)    Thrombocytopenia
                (C)    Acute Infection
                (D)    Leukemia

6.       A 60-year-old man is 7 days post-op from a heart transplant. He is to be transferred out of the
         ICU tomorrow The nurse will know that her teaching about post-transplant care has been
         successful when the client states:
                (A)    “I can stop taking these immunosuppressant medications after I feel better.”
                (B)    “I need to avoid crowds and persons with colds.”
                (C)    “I can never kiss my wife again because I can get an infection.”
                (D)    “I will never be able to go hunting again.”

7.       A nitropruaside (Nipride) drip is prepared by mixing 50mg of the drug in 250ml of DSW.
         The nurse is instructed to administer 3mcg/kg/minute. The patient weights 89kg. Which of
         the following drip rates is correct (the drip factor of the pump tubing is 60gtt/ml)?
                (A)    10 ml/hour
                (B)    32 ml/hour
                (C)    80 ml/hour
                (D)    75 ml/hour

8.       A 29-year-old women arrives in the ER exhibiting audible wheezes and complaining of
         dyspnea and anxiety. The physician's diagnosis is status asthmaticus. The patient's vital signs
         and lab work are:
                   BP165/94 mmHG         pH 7.32                    CO3 - 24 mEg/liter
                   HR 120 beats/min      Sao2 87%                   Hemoglobin 14.4 g/dl
                   RR 44 breaths/min     PaCO2 62 mm Hg
                   T 97.8 F              PaO2 74 mm Hg
         Ausculation reveals coarse crackles and wheezes. Inspection reveals forceful exhalation,
         diaphoresis, use of accessory muscles, and pale color skin. The physician orders ephineherine
         0.1 mg SC and an aminophyllines IV infusion rate at 0.5 mg/kg/hr. When the patient's hear
         rate increases to 170 beats/minute, what should the nurse do?
                (A)    Stop the aminophylline infusion and notify the physician
                (B)    Increase the aminophylline infusion and notify the physician
                (C)    Teach the patient to do pursed lipped breathing
                (D)    Provide a quite atmosphere to promote relaxation


                                   CA Correctional RN ICU Employment Application Packet v-3 121007                  Page 15 of 23

     5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                            Tel: 877.687.7399   Fax: 877.687.7400
9.       A patient suffered a major burn injury and is diagnosed with adult respiratory distress
         syndrome (ARDS). His nurse is formulating a nursing care plan to reflect ARDS and knows
         that the goals with the highest priority should include:
                (A)    Improving the patient’s nutritional status and decreasing his pulmonary compliance
                (B)    Administering steroids and antibiotics to combat infection
                (C)    Lowering the client’s blood pressure and increasing his PaCO2 level
                (D)    Maintaining adequate oxygenation and eliminating underlying causes of ARDS

10.      A patient is intubated and is connected to a mechanical ventilator. The murse would
         recognize an accumulation of secretions that alter the patient's airway resistance by which of
         the following responses?
                (A)    Sudden decrease in the positive and expiratory pressure (PEEP)
                (B)    Gradual decrease in the inspired tidal volume
                (C)    Increase in the amount of pressure required to deliver the selected tidal volume
                (D)    Increase in the tidal volume without pressure changes

11.      A 46-year-old teacher with advanced cirrhosis is being examined by the emergency
         department nurse. What can the nurse expect to find when palpating the client's liver?
                (A)    Rebound tenderness
                (B)    Enlarged, soft, painful mass
                (C)    Enlarged, hard, painless mass
                (D)    Enlarged, soft mass

12.      A 38-year-old man is admitted into the ICU with a diagnosis of DIC following a serious
         automobile accident. Which nursing diagnosis would have the highest priority?
                (A)    Impaired skin integrity related to immobility
                (B)    Anxiety related to fear of dying
                (C)    Fluid volume deficit related to excessive bleeding
                (D)    Impaired gas exchange related to bleeding in the lungs

13.      A patient is diagnosed with acute transmural MI. While analyzing the patient's ECG strip, the
         nurse would find that the ST segment is:
                (A)    Isoelectric
                (B)    Elevated
                (C)    Prolonged
                (D)    Depressed




                                   CA Correctional RN ICU Employment Application Packet v-3 121007                  Page 16 of 23

     5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                            Tel: 877.687.7399   Fax: 877.687.7400
14.   Which of the following are the expected compensatory cardiovascular mechanisms in respond
      to shock?
            (A)    Increased pulse rate and increased contractility of the heart
            (B)    Decreased pulse rate and increased contractility of the heart
            (C)    Increased heart rate and decreased contractility of the heart
            (D)    Decreased pulse rate and decreased contractility

15.   A patient is transferred from the medical unit to the critical care unit complaining of a rapid
      heartbeat, shortness of breath, and syncope. Cardiac monitoring shows supraventricular
      tachycardia. Vital signs reveal a pulse of 164 beats/minute, blood pressure 80/50mm Hg, and
      respiration 28 breaths/minute. IV access is established and oxygen is administered. The
      critical care nurse should anticipate an order for which of the following drugs?
            (A)    Digoxin (Lanoxin)
            (B)    Diltiazem (Cardizem)
            (C)    Bretylium (Bretylol)
            (D)    Adenosine (Adenocard)

16.   Bradycardia and artrioventricular node conduction disturbances are most often associated with
      which of the following conditions?
            (A)    Cardiogenic shock
            (B)    Anterior wall infarction
            (C)    Inferior wall infarction
            (D)    Heart failure

17.   A patient presents to the emergency department complaining of sudden onset of chest pain
      that increases with deep breathing and lying flat. The pain decreases somewhat with sitting up
      and leaning forward. Vital signs are blood pressure 100/60 mm Hg, pulse 100 beats/minute,
      respiration 22 breaths/minute, and temperature 103.4 F (39.7C). Which of the following
      should the emergency nurse suspect?
            (A)    Myocardial infarction
            (B)    Pleurisy
            (C)    Pericarditis
            (D)    Endocarditis




                               CA Correctional RN ICU Employment Application Packet v-3 121007                  Page 17 of 23

 5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                            Tel: 877.687.7399   Fax: 877.687.7400
18.   Adenosine is administered to a patient with paroxysmal supraventricular tachycardia. The
      patient complains of faintness and becomes pale. The monitor shows asytole. The critical
      care nurse should do which of the following?
            (A)    Begin CPR
            (B)    Administer 1 mg of atropine sulfate by IV push
            (C)    Observe the patient for several seconds
            (D)    Administer epinephrine (Adrenalin) by IV push

19.   Which of the following is the primary effect of thromobolytic therapy?
            (A)    Reperfusion arrhythmia
            (B)    Bleeding
            (C)    Release of oxygen free radicals
            (D)    Hypotension

20.   During patient assessment, the nurse finds the patient's pupils to be pinpoint. What might this
      indicate?
            (A)    Opiod overdose
            (B)    Midbrain damage
            (C)    Severe anoxia
            (D)    Previous cataract surgery

21.   Which lung sounds requires immediate nursing intervention?
            (A)    Crackles
            (B)    Rhonchi
            (C)    Stridor
            (D)    Wheezing

22.   Which of the following is the earliest indicator of a change in a patient's neurologic status?
            (A)    Pupillary reaction
            (B)    Motor response
            (C)    Capillary refill
            (D)    Level of conscoiusness

23.   Which acid-base imbalance is most likely seen in apatient with chronic obstructive pulmonary
      disease?
            (A)    Metabolic acidosis
            (B)    Respiratory acidosis
            (C)    Metabolic alkalosis
            (D)    Respiratory alkalosis
                               CA Correctional RN ICU Employment Application Packet v-3 121007                  Page 18 of 23

 5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                            Tel: 877.687.7399   Fax: 877.687.7400
24.   Which of the following is the purpose of corticosteroids in a patient with a brain tumor?
            (A)    Control absence seizures
            (B)    Provides symptomatic relief of agitation
            (C)    Reduce cerebral edema
            (D)    Reduce pain

25.   Which is the most effective treatment of intrapulmonary hunt in the adult repiratory distress
      syndrome patient?
            (A)    Administer a diuretic
            (B)    Increase the FiO2
            (C)    Implement positive end-expiratory pressure
            (D)    Decrease fluid intake

26.   Arterial blood gas measurements for a trauma patient consist of pH 7.48, PaCO2 30mm Hg,
      PaO2 84 mm Hg, HCO3 - 22 mEq/L. The patient is in which metabolic state?
            (A)    Metabolic acidosis
            (B)    Respiratory alkalosis
            (C)    Respiratory Acidosis
            (D)    Metabolic alkalosis

27.   Which of the following in a contraindication for lumbar puncture?
            (A)    Increased intracranial pressure
            (B)    Wafarin sodium (Coumadin) therapy
            (C)    Infection of the cutaneous or osseous areas at the lumbar puncture site
            (D)    All of the above

28.   Which of the following does treatment for hyperkalemia include?
            (A)    Administration of 10% glucose infusion with regular insulin
            (B)    Administration of stored blood
            (C)    Administration of calcium gluconate
            (D)    None of the above

29.   Which is the main priority in the care of the patient with acute pancreatitis?
            (A)    Pain control
            (B)    Nutritional support
            (C)    Casual correction
            (D)    Fluid resuscitation

                               CA Correctional RN ICU Employment Application Packet v-3 121007                  Page 19 of 23

 5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                            Tel: 877.687.7399   Fax: 877.687.7400
30.   A patient receiving beta blockers shows which response to a shock state?
            (A)    Increased pulse rate and hypotension
            (B)    Bradycardia, Hypotension and decreased rennin secretion
            (C)    Increase pulse rate and hypertension
            (D)    Bradycardia and hypertension

31.   The lowest level of electrical energy required to initiate consistent capture with a pacemaker is
      referred to as which of the following?
            (A)    Underdrive pacing
            (B)    Packing threshold
            (C)    Sensing threshold
            (D)    Demand pacing

32.   Which of the following diagnostic findings indicates the need for mechanical ventilation?
            (A)    A PaO2 of 80 mm Hg on room air
            (B)    A vital capacity of less than 10 ml/kg
            (C)    A normal work of breathing
            (D)    A PaCO2 of 42 mm Hg

33.   The doctor orders a continuous infusion of epinepherine (Adrenalin) 1 mg in 250 ml of D5W
      by way of infusion pump at 1.25 mcg/minute. What is the infusion rate in milliters per hour
      (assuming the use of microdrip 60 gtt/ml tubing)?
            (A)    34 ml/hour
            (B)    23 ml/hour
            (C)    15 ml/hour
            (D)    19 ml/hour

34.   Why should Allen's test be performed before the insertion of an arterial line?
            (A)    To ensure the monitor has been zeroed correctly
            (B)    To ensure collateral circulation to the hand is adequate
            (C)    To ensure that no phelibitis is present in the radial artery
            (D)    To ensure that the transducer is at the level of the right atrium

35.   The pumping ability of the heart depends on which of the following four factors?
            (A) Contractility, preload, heart rate, afterload
            (B) Contractility, heart rate, cardiac output, cardiac index
            (C) Heart rate, cardiac output, left ventricular hypertrophy, pulmonary venous
                congestion
            (D) None of the above
                               CA Correctional RN ICU Employment Application Packet v-3 121007                  Page 20 of 23

 5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                            Tel: 877.687.7399   Fax: 877.687.7400
36.   Initial treatment for the adult patient with a sever anaphylatic reaction includes which o f the
      following drugs?
            (A)    Administration of diphenhydramine (Benadryl) 25 mg IM
            (B)    Administration of ephinephrine 0.1 to 0.5 mf of a 1:1,000 solution
            (C)    Administration of epinephrine 0.1 to 0.25 mf of a 1:10,000 solution
            (D)    Cimetadine (Tagamet) 300 mg IV

37.   Which are the most frequent early systemic signs of septic shock?
            (A) Hyperthemia, tachycardia, wide pulse pressure, tachypnea, respiratory alkalosis,
                and mental obtundation
            (B) Hypothemia, bradycardia, narrow pulse pressure, tachypnea, respiratory acidosis,
                and coma
            (C) Hypothemia, tachycardia, narrow pulse pressure, tachypnea, respiratory acidosis,
                and confusion
            (D) Hyperthemia, bradycardia, wide pulse pressure, tachypnea, respiratory acidosis,
                and mental obtundation




                               CA Correctional RN ICU Employment Application Packet v-3 121007                  Page 21 of 23

 5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                            Tel: 877.687.7399   Fax: 877.687.7400
                                                 RHYTHMS TEST
Name:                                                                                   Date:

For the following graphs, identify the rhythms:

1.       Rhythm:




2.       Rhythm:




3.       Rhythm:




4.       Rhythm:




                                   CA Correctional RN ICU Employment Application Packet v-3 121007                  Page 22 of 23

     5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                            Tel: 877.687.7399   Fax: 877.687.7400
5.       Rhythm:




6.       Rhythm:




7.       Rhythm:




8.       Rhythm:




                                   CA Correctional RN ICU Employment Application Packet v-3 121007                  Page 23 of 23

     5255 Stevens Creek Blvd. #155, Santa Clara, CA 95051-6664                            Tel: 877.687.7399   Fax: 877.687.7400

				
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