ATI RN
Critical Care Nursing Questions Questions
Question 1 of 5
The nurse is caring for a patient with severe neurological impairment following a massive stroke. The primary care provider has ordered tests to detearbmirbi.ncoem b/treasit n death. The nurse understands that criteria for brain death includes what crite ria? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Absence of cerebral blood flow. Brain death is determined by the irreversible cessation of all brain functions, including blood flow to the brain. When there is no cerebral blood flow, the brain is unable to function, leading to brain death. This criterion is essential in diagnosing brain death as it indicates a complete loss of brain function.
Explanation for why the other choices are incorrect:
- B: Absence of brainstem reflexes on neurological examination is a common sign of brain death, but it is not the primary criterion.
- C: Presence of Cheyne-Stokes respirations is not indicative of brain death. It is a pattern of breathing that can be seen in various conditions, not specifically brain death.
- D: Confirmation of a flat electroencephalogram is a supportive test for brain death but not the primary criterion. The absence of brain activity on an EEG can help confirm brain death but is not as definitive as the absence of cerebral blood flow.
Question 2 of 5
A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats per minute. What action should the nurse implement next?
Correct Answer: D
Rationale: The correct answer is D: Administer the medication. Atenolol is a beta-blocker used to reduce heart rate and blood pressure. In this scenario, the client's apical pulse of 65 beats per minute is within the normal range for a client taking atenolol after a myocardial infarction.
Therefore, the nurse should proceed with administering the medication as prescribed to help maintain the client's heart rate and blood pressure within the therapeutic range.
A: Measuring the blood pressure is important but not the immediate next step as the client's heart rate is within the normal range.
B: Reassessing the apical pulse is unnecessary since it is already within the normal range for a client on atenolol.
C: Notifying the healthcare provider is not indicated as there are no signs of concern with the client's heart rate at 65 bpm.
Question 3 of 5
What were identified as the first critical care units? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Burn units. Burn units were identified as the first critical care units due to the complex and intensive care required by burn patients. These units were established to provide specialized care for burn victims, including wound management, infection control, and fluid resuscitation.
Summary:
- Burn units were the first critical care units due to the specialized care needed for burn patients.
- Coronary care units focus on cardiac conditions, not the first identified critical care units.
- Recovery rooms are for post-operative care, not specifically for critical care.
- Neonatal intensive care units are specialized for newborns, not the first critical care units.
Question 4 of 5
A patient nearing death experiences increased secretions and noisy breathing. What is the nurse’s priority intervention?
Correct Answer: B
Rationale: The correct answer is B: Administer anticholinergic medications as prescribed. Anticholinergic medications can help dry up secretions and improve breathing in a patient nearing death. This intervention targets the underlying cause of increased secretions. Suctioning (choice
A) may provide temporary relief but does not address the root issue. Elevating the head of the bed and repositioning (choice
C) can help with comfort but do not directly address the secretions. Restricting oral intake (choice
D) may lead to dehydration and discomfort without effectively managing the secretions. Administering anticholinergic medications is the priority as it directly targets the symptom of increased secretions, improving the patient's comfort and quality of life.
Question 5 of 5
A 100-kg patient gets hemodialysis 3 days a week. In planning the care for this patient, the nurse recommends
Correct Answer: A
Rationale: The correct answer is A: a diet of 2500 to 3500 kcal per day. During hemodialysis, the patient loses nutrients and energy, so a high-calorie diet is necessary to maintain proper nutrition and energy levels. 2500-3500 kcal/day is a suitable range for a 100-kg patient.
Choice B is incorrect because protein intake should be adequate to prevent malnutrition in hemodialysis patients, typically 1.2g/kg body weight/day.
Choice C is incorrect as potassium intake should be restricted in hemodialysis patients due to impaired kidney function.
Choice D is incorrect because fluid intake should be individualized based on the patient's fluid status and should not be limited to less than 500 mL per day.