ATI RN
Critical Care Nursing Questions and Answers PDF Questions
Question 1 of 5
A 68-year-old patient has been in the intensive care unit for 4 days and has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action should the nurse include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Cluster nursing activities so that the patient has uninterrupted rest periods. Rationale: 1. Clustering nursing activities allows for uninterrupted rest periods, essential for improving sleep quality and addressing disturbed sensory perception. 2. Administering sedatives or opioids (Option A) can lead to drug dependence, tolerance, and adverse effects in older adults. 3. Silencing alarms (Option C) compromises patient safety by impeding timely monitoring and response to critical events. 4. Eliminating assessments (Option D) between 0100 and 0600 disregards the necessity of monitoring vital signs and assessing patient condition around the clock.
Question 2 of 5
An intra-aortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met?
Correct Answer: C
Rationale: The correct answer is C: Cardiac output (CO) of 5 L/min. In cardiogenic shock, the primary goal of using an IABP is to improve cardiac output to ensure adequate perfusion to vital organs. A cardiac output of 5 L/min indicates adequate blood flow and perfusion. Choice A is incorrect as urine output is not a direct indicator of cardiac function. Choice B is incorrect as a heart rate of 110 beats/minute alone does not provide information on the effectiveness of the IABP in improving cardiac output. Choice D is incorrect as stroke volume alone does not provide a comprehensive assessment of overall cardiac function.
Question 3 of 5
Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?
Correct Answer: C
Rationale: The correct answer is C because a respiratory rate of 32 breaths/minute indicates increased work of breathing, which could be due to secretions that need to be suctioned. High respiratory rate may suggest inadequate oxygenation and ventilation. Oxygen saturation of 93% (choice A) is within an acceptable range and does not necessarily indicate the need for suctioning. Time since last suctioning (choice B) should be considered but is not as immediate an indication as an increased respiratory rate. Occasional audible expiratory wheezes (choice D) may be indicative of other respiratory issues but do not directly indicate the need for suctioning.
Question 4 of 5
When caring for a patient with a pulmonary artery (PA) pressure catheter, the nurse observes that the PA waveform indicates that the catheter is in the wedged position. Which action should the nurse take next?
Correct Answer: C
Rationale: The correct answer is C: Notify the health care provider. When the PA waveform indicates the catheter is in the wedged position, it means the catheter tip is in the pulmonary artery, potentially causing complications. The nurse should notify the healthcare provider immediately to assess and reposition the catheter to prevent further issues. Zero balancing the transducer (A) or activating the fast flush system (B) are not appropriate actions for this situation. Deflating and reinflating the PA balloon (D) could exacerbate the issue and should only be done under the guidance of the healthcare provider.
Question 5 of 5
The nurse notes that a patient’s endotracheal tube (ET), which was at the 22 cm mark, is now at the 25 cm mark and the patient is anxious and restless. Which action should the nurse take next?
Correct Answer: C
Rationale: The correct answer is C: Listen to the patient’s breath sounds. Moving from 22 cm to 25 cm may indicate ET tube migration. Checking breath sounds can confirm proper tube placement. A may not address the underlying issue. B could worsen the situation if the tube is misplaced. D is not urgent compared to assessing airway integrity.