ATI RN
Introduction to Critical Care Nursing 8th Edition Questions
Question 1 of 5
A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 mm Hg, and heart rate is 132 beats/min. Based on this information, which patient problem is the priority?
Correct Answer: D
Rationale: The correct answer is D: Decreased cardiac output. In a patient with STEMI, a low blood pressure and high heart rate indicate decreased cardiac output, which is a life-threatening condition. Addressing this issue is crucial to prevent further complications like cardiogenic shock. Anxiety (A), acute pain (B), and stress management (C) are important but not immediate priorities in this scenario. Managing the patient's hemodynamic stability is paramount to ensure adequate tissue perfusion and prevent further deterioration.
Question 2 of 5
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?
Correct Answer: C
Rationale: The correct answer is C because during an acute episode of respiratory distress, it is essential to quickly gather specific information about the current situation. This allows the nurse to assess the severity of the issue, identify potential causes, and provide immediate interventions. Asking specific questions about the episode helps in determining the onset, triggers, associated symptoms, and any previous similar episodes. This information guides the nurse in prioritizing care and initiating appropriate interventions promptly. Choice A is incorrect because asking the patient to lie down for a full physical assessment is not appropriate during acute respiratory distress as it delays crucial information gathering. Choice B is incorrect as completing the health history and checking for allergies can be done after addressing the immediate respiratory distress. Choice D is incorrect because delaying the physical assessment for pulmonary function tests is not indicated in the acute management of respiratory distress.
Question 3 of 5
A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective?
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 4 of 5
A nurse cares for a client after radiation therapy for neck cancer. The client reports extreme dry mouth. What action by the nurse is most appropriate?
Correct Answer: C
Rationale: Rationale: Option C is correct because xerostomia (dry mouth) is a common side effect of radiation therapy to the head and neck area. It is important for the nurse to educate the client about this potential side effect and provide strategies for managing it. This includes encouraging the client to stay hydrated, suck on sugar-free candy, and avoid alcohol and tobacco. Option A is incorrect as lidocaine-containing mouthwash may not be appropriate for long-term use and may not effectively address the underlying issue of dry mouth. Option B is also incorrect as IV fluid boluses are not indicated for managing dry mouth. Option D is incorrect as assessing the client's neck for redness and swelling is not directly related to the client's complaint of dry mouth.
Question 5 of 5
An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse is best?
Correct Answer: A
Rationale: The correct answer is A: Assess the client's lung sounds. This is the best action because coughing during a meal with a tracheostomy could indicate aspiration, which can lead to respiratory complications. Assessing lung sounds can help determine if there are any signs of respiratory distress. B: Assign a different AP to the client - This is not the best action as the priority is to assess the client's condition first. C: Report the AP to the manager - This is not the best action as the immediate concern is the client's well-being and assessing their condition. D: Request thicker liquids for meals - This is not the best action as it does not address the potential respiratory issue the client may be experiencing.