ATI RN
Critical Care Nursing Questions and Answers PDF Questions
Question 1 of 5
A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with a basilar skull fracture?
Correct Answer: C
Rationale: The correct answer is C: Rhinorrhoea or otorrhoea with Halo sign. This finding is consistent with a basilar skull fracture because it indicates a cerebrospinal fluid (CSF) leak from the skull base. The Halo sign refers to a ring of CSF surrounded by blood, which can be seen on a white absorbent pad. This specific sign is a classic indicator of a basilar skull fracture, as the CSF leakage from the ears or nose can be tinged with blood due to the fracture disrupting nearby blood vessels.
For the other choices:
A: Hematemesis and abdominal distention are not typical manifestations of a basilar skull fracture. They are more indicative of gastrointestinal issues or internal bleeding.
B: Asymmetry of the face and eye movements can be seen with facial nerve or orbital injuries, but it is not specific to a basilar skull fracture.
D: Abnormal position and movement of the arm are not directly related to a
Question 2 of 5
The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Remove the patient's rings first. This is crucial to prevent constriction and swelling due to potential allergic reactions or inflammation from bee stings. Removing rings allows for proper circulation and prevents complications like compartment syndrome. Ice packs (
B) can be applied after removing the rings to reduce swelling. Calamine lotion (
C) can provide relief for itching but is not as urgent as ring removal. Diphenhydramine (
D) can be given later for systemic allergic reactions but should not take precedence over removing the rings.
Question 3 of 5
Which action by the nurse demonstrates cultural sensitivity in end-of-life care?
Correct Answer: C
Rationale: The correct answer is C because inquiring about specific cultural rituals and preferences shows respect for the patient's cultural beliefs and values. By asking about these aspects, the nurse can provide care that aligns with the patient's cultural background, promoting comfort and understanding. This action also demonstrates a commitment to individualized care.
Choice A is incorrect because standardized care may not always be culturally appropriate.
Choice B is incorrect as avoiding discussions about death can hinder effective communication and support.
Choice D is incorrect as advising families to strictly follow hospital guidelines may overlook the importance of cultural considerations in end-of-life care.
Question 4 of 5
The nurse is assessing a patient with a new arteriovenous fistula, but does not hear a bruit or feel a thrill. Pulses distal to the fistula are not palpable. The nurse should
Correct Answer: C
Rationale: The correct answer is C: notify the provider immediately. The absence of bruit, thrill, and palpable distal pulses in a new arteriovenous fistula suggests potential complications like thrombosis or stenosis, requiring urgent intervention. Notifying the provider promptly allows for timely assessment and appropriate management to prevent further complications.
Summary:
A: Reassessing the patient in an hour may delay necessary intervention for a potentially serious issue.
B: Raising the arm above the level of the patient’s heart does not address the underlying problem and may not improve the situation.
D: Applying warm packs to the fistula site is not the appropriate intervention for the absence of bruit and thrill and may not address the underlying cause.
Question 5 of 5
The nurse is caring for a mechanically ventilated patient an d is charting outside the patient’s room when the ventilator alarm sounds. What is the priorit y order for the nurse to complete these actions? (Put a comma and space between each answer choice.)
Correct Answer: C
Rationale:
Step-by-step rationale for why choice C is correct:
1. Going to the patient’s bedside is the priority as it allows the nurse to assess the patient's condition directly.
2. By being at the bedside, the nurse can quickly evaluate the patient's breathing, vital signs, and other indicators for immediate action.
3. Direct assessment enables timely intervention and avoids delays in addressing potential life-threatening situations.
4. Checking for possible causes of the alarm and reconnection to the ventilator can follow, but assessing the patient's immediate needs takes precedence.
In summary, choice C is correct because direct patient assessment is the fundamental step in responding to a ventilator alarm to ensure patient safety and timely intervention.
Choices A, B, and D are incorrect as they focus on troubleshooting and technical aspects before directly assessing the patient's condition.