ATI RN
Critical Care Nursing Practice Questions Questions
Question 1 of 5
A family member approaches the nurse caring for their gra vely ill son and states, “We want to donate our son’s organs.” What is the best action by the nu rse?
Correct Answer: C
Rationale: The correct answer is C: Notify the organ procurement organization (OPO). This is the best action because the OPO is responsible for coordinating organ donation and transplantation. By involving the OPO, the nurse ensures that the donation process is handled appropriately and ethically. Choice A: Arranging a multidisciplinary meeting with physicians may be necessary but should not be the first step in this situation. Choice B: Consulting the hospital’s ethics committee may be helpful, but the immediate priority is to involve the OPO to facilitate organ donation. Choice D: Obtaining family consent to withdraw life support is not the nurse’s role in this situation. The focus should be on organ donation to honor the family's wishes.
Question 2 of 5
What is the best way to monitor agitation and effectivenes s of treating it in the critically ill patient?
Correct Answer: D
Rationale: The correct answer is D: Richmond Agitation Sedation Scale (RASS). RASS is specifically designed to monitor agitation and sedation levels in critically ill patients, providing a standardized and objective assessment. It includes clear descriptors for different levels of agitation and sedation, allowing for consistent monitoring and treatment adjustments. CAM-ICU is mainly used for delirium assessment, not agitation. FACES assessment tool is more appropriate for pain assessment. Glasgow Coma Scale is focused on assessing level of consciousness, not agitation specifically. By using RASS, healthcare providers can accurately track agitation levels and evaluate the effectiveness of interventions in managing agitation in critically ill patients.
Question 3 of 5
The nurse is caring for a patient diagnosed with hyperactivaebi rdb.ecloimri/tuemst . The nurse focuses interventions toward which priority need?
Correct Answer: C
Rationale: The correct answer is C: Safety. In hyperactive delirium, the patient may be agitated, disoriented, and at risk of harm. Safety is the priority to prevent falls or injury. Comfort (A) is important but secondary to safety in this case. Nourishment (B) can wait until safety is ensured. Sedation (D) may be considered but only after safety measures are in place.
Question 4 of 5
Which of the following statements regarding pain and anxiety are true? (Select all that apply.)
Correct Answer: A
Rationale: Rationale: A: Correct. Anxiety is characterized by apprehension, agitation, autonomic arousal, and fearful withdrawal, which are distinct from pain. B: Incorrect. Critically ill patients can experience both anxiety and pain, as pain is not exclusive to them. C: Incorrect. While pain and anxiety can be interrelated, they can be differentiated based on their unique physiological and behavioral manifestations. D: Incorrect. Pain is a subjective experience, but it is not solely defined by the individual; objective assessments are also important.
Question 5 of 5
The nurse is caring for a 48-year-old patient who is intubated and on a ventilator following extensive abdominal surgery. Although the patient is respo nsive, the nurse is not able to read the patient’s lips as the patient attempts to mouth the words. Which of the following assessment tools would be the most appropriate for the nu rse to use when assessing the patient’s pain level? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: The FACES scale. This scale uses facial expressions to assess pain, making it suitable for a patient who is unable to verbalize. The nurse can show the patient a series of faces depicting varying levels of pain and ask them to point to the one that best represents their pain level. This method is non-verbal and easy for patients to understand. The other choices are incorrect: B: The Pain Intensity Scale requires the patient to rate their pain on a numerical scale, which may be difficult for a non-verbal patient. C: The PQRST method is a mnemonic for assessing pain characteristics (provocation, quality, region, severity, timing), but it requires patient communication. D: The Visual Analogue Scale involves marking a point on a line to indicate pain intensity, which is not suitable for a non-verbal patient.