ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 of 9
A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma?
Correct Answer: D
Rationale: The correct answer is D, Metoprolol tartrate (Lopressor). Metoprolol is a cardioselective beta-blocker that primarily targets beta-1 receptors in the heart, making it less likely to exacerbate asthma compared to non-selective beta-blockers like Propranolol (choice B) and Pindolol (choice C). Carteolol (choice A) is also a non-selective beta-blocker and can potentially worsen asthma symptoms. Metoprolol's selectivity for beta-1 receptors minimizes bronchoconstriction, making it the safest choice for a client with asthma and high blood pressure.
Question 2 of 9
Following an earthquake, patients are triaged by emergency medical personnel and are transported to the emergency department (ED). Which patient will the nurse need to assess first?
Correct Answer: A
Rationale: The correct answer is A: A patient with a red tag. In triage, red tags indicate patients with life-threatening injuries who require immediate attention. The nurse must assess this patient first to provide necessary interventions. Patients with blue tags are considered urgent but stable, black tags are deceased or beyond help, and yellow tags are for delayed treatment. Assessing the red-tagged patient first ensures prompt care for those in critical condition.
Question 3 of 9
As part of the admission process, the nurse asks several questions about family relationships. The nurse bases these actions on which rationale?
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct: 1. Involving the family in patient care is crucial for holistic care. 2. Assessing family relationships helps identify support systems and potential conflicts. 3. Understanding family dynamics aids in creating a comprehensive care plan. 4. Family involvement can enhance patient outcomes and satisfaction. Summary of incorrect choices: B. Irrelevant, as the focus is on patient-centered care, not just fulfilling an assessment tool. C. Personal curiosity is not a valid reason for assessing family relationships in healthcare. D. Conducting research on family patterns does not directly impact the immediate care of the patient.
Question 4 of 9
The nurse is caring for a mechanically ventilated patient. T he primary care providers are considering performing a tracheostomy because the patienatb iirsb .hcoamv/itensgt difficulty weaning from mechanical ventilation. Related to tracheostomy, the nurse understands which of the following?
Correct Answer: C
Rationale: The correct answer is C: Procedures performed in the operating room are associated with fewer complications. This is because performing a tracheostomy in the operating room allows for better control of the environment, equipment, and expertise of the surgical team. In this setting, the risk of complications such as bleeding, infection, and injury to surrounding structures is minimized. Choices A, B, and D are incorrect: A: Patient outcomes are better if the tracheostomy is done within a week of intubation - This statement is not universally true and depends on individual patient factors. Timing of tracheostomy should be based on the patient's clinical condition and not a set timeline. B: Percutaneous tracheostomy can be done safely at the bedside by the respiratory therapist - While percutaneous tracheostomy can be performed at the bedside, it is typically done by a trained physician or surgeon due to the potential risks and complications involved. D: The greatest risk after a per
Question 5 of 9
The nurse is assessing the critically ill patient for delirium . The nurse recognizes which characteristics that indicate hyperactive delirium? (Select aabllir bt.hcaomt /atepstp ly.)
Correct Answer: A
Rationale: The correct answer is A: Agitation. In hyperactive delirium, patients often exhibit restlessness, agitation, and hyperactivity. This behavior is a key characteristic indicating hyperactive delirium. Apathy (B), biting (C), and hitting (D) are not typically associated with hyperactive delirium. Apathy may be seen in hypoactive delirium, while biting and hitting are not specific indicators of delirium subtypes. Therefore, the correct choice is A as it aligns with the typical presentation of hyperactive delirium.
Question 6 of 9
The nurse observes that an elderly woman, whose granddaughter has been admitted to theICU, is struggling to manage her two great-grandsons, who are toddlers, in the waiting room. What is the most likely explanation for the womans inability to manage the children in this situation?
Correct Answer: B
Rationale: The correct answer is B: She is in the exhaustion stage of the general adaptation syndrome to stress. Rationale: 1. In the exhaustion stage, the body's resources are depleted due to prolonged stress, leading to fatigue and reduced ability to cope. 2. The elderly woman is likely experiencing high levels of stress due to her granddaughter's critical condition. 3. Managing toddlers while dealing with the emotional distress of a loved one in the ICU can be overwhelming, causing exhaustion. 4. This explanation aligns with the symptoms of fatigue and difficulty managing the children observed by the nurse. Summary: A: Incorrect. Senility is a cognitive condition unrelated to the stress of the situation. C: Incorrect. Assuming a caregiver role can be stressful, but it does not explain the observed exhaustion. D: Incorrect. Macular degeneration affects vision, not the ability to manage stress and children.
Question 7 of 9
A patient in hospice care is experiencing dyspnea. What is the most appropriate nursing intervention?
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen as prescribed. Dyspnea in a hospice patient often indicates respiratory distress, and administering oxygen can help improve oxygenation and alleviate breathing difficulty. Positioning the patient flat on their back (A) may worsen dyspnea due to increased pressure on the diaphragm. Restricting fluid intake (C) is not appropriate as dehydration can exacerbate respiratory distress. Chest physiotherapy (D) may not be suitable for a hospice patient experiencing dyspnea as it can be physically taxing and may not address the underlying cause effectively.
Question 8 of 9
What are the diagnostic criteria for acute respiratory distress syndrome (ARDS)? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Bilateral infiltrates on chest x-ray study. ARDS diagnosis requires bilateral infiltrates on chest x-ray, indicative of non-cardiogenic pulmonary edema. Choice B, decreased cardiac output, is not a diagnostic criterion for ARDS. Choice C, PaO2/FiO2 ratio of less than 200, is a key diagnostic criteria for ARDS, indicating severe hypoxemia. Choice D, PAOP of more than 18 mm Hg, is used to differentiate between cardiogenic and non-cardiogenic causes of pulmonary edema, but it is not a direct diagnostic criterion for ARDS.
Question 9 of 9
The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder?
Correct Answer: A
Rationale: Step 1: Symptoms of weight loss, racing heart rate, and difficulty sleeping are common in hyperthyroidism. Step 2: Presence of moist skin, fine hair, prominent eyes, lid retraction, and staring expression are classic signs of Grave's disease, a type of hyperthyroidism. Step 3: Grave's disease is an autoimmune disorder where the thyroid gland is overactive, leading to excessive production of thyroid hormones. Step 4: Excess thyroid hormones increase metabolic rate, causing weight loss, racing heart rate, and insomnia. Step 5: Therefore, the findings described in the question are consistent with Grave's disease.