ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 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 2 of 9
The patient has elevated blood urea nitrogen (BUN) and serum creatinine levels with a normal BUN/creatinine ratio. These levels most likely indicate
Correct Answer: B
Rationale: The elevated BUN and creatinine levels with a normal BUN/creatinine ratio indicate impaired kidney function. This pattern is commonly seen in acute kidney injury, such as acute tubular necrosis (ATN). In ATN, there is damage to the renal tubules leading to decreased excretion of waste products, resulting in elevated BUN and creatinine levels. The normal BUN/creatinine ratio suggests that the impairment is due to renal tubular dysfunction rather than prerenal causes like hypovolemia or postrenal causes like urinary obstruction. Increased nitrogen intake would not produce this specific pattern of results. Fluid resuscitation would likely result in dilution of BUN and creatinine levels, leading to lower values.
Question 3 of 9
The nurse is assisting with endotracheal intubation of the p atient and recognizes that the procedure will be done in what order? (Put a comma and s pace between each answer choice.)
Correct Answer: D
Rationale: The correct answer is D. The first step in endotracheal intubation is to insert the endotracheal tube with a laryngoscope and blade to visualize the vocal cords and guide the tube into the trachea. This ensures proper placement of the tube for effective ventilation. Assessing the balloon symmetry (Choice A) and lung fields (Choice B) would come after the tube is successfully inserted. Inflating the balloon of the endotracheal tube (Choice C) should be the last step to secure the tube in place.
Question 4 of 9
A critical care unit has decided to implement several measures designed to improve intradisciplinary and interdisciplinary collaboration. In addition to an expected improvement in patient outcomes, what is the most important effect that should resultf rom these measures?
Correct Answer: C
Rationale: Rationale: - Improved collaboration enhances job satisfaction and reduces burnout, leading to increased staff retention. - Higher staff retention promotes continuity of care, improves team dynamics, and enhances patient outcomes. Summary: - A: Not directly related to collaboration, more about performance evaluation. - B: Manners may improve, but not the most important effect of collaboration. - D: Collaboration involves open communication, so less discussion in front of patients is not a positive outcome.
Question 5 of 9
A nurse who plans care based on the patient’s gender, ethn ai bc iri bt .y co, ms /p tei sr ti tuality, and lifestyle is said to demonstrate what focus?
Correct Answer: C
Rationale: The correct answer is C: Responding to diversity. By considering the patient's gender, ethnicity, spirituality, and lifestyle, the nurse is focusing on responding to diversity in patient care. This approach acknowledges and respects the unique characteristics and backgrounds of individual patients, leading to more culturally competent and effective care. Choice A: Becoming a moral advocate does not directly relate to considering diversity in patient care. It involves standing up for ethical principles and values in healthcare. Choice B: Facilitating all forms of learning is not specific to addressing diversity in patient care. It pertains to promoting education and understanding in various learning styles. Choice D: Using effective clinical judgment is important in nursing practice but does not specifically address the focus on diversity in patient care. It pertains to making sound decisions based on clinical knowledge and expertise.
Question 6 of 9
A PaCO 2 of 48 mm Hg is associated with what outcome?
Correct Answer: B
Rationale: The correct answer is B: Hypoventilation. A PaCO2 of 48 mm Hg indicates an elevated level of carbon dioxide in the blood, which is typically seen in hypoventilation where the lungs are not effectively removing CO2. Hypoventilation leads to respiratory acidosis. Option A is incorrect because hyperventilation would decrease PaCO2 levels. Option C is incorrect as it does not directly relate to PaCO2 levels. Option D is incorrect as increased excretion of HCO3- would not directly affect PaCO2 levels.
Question 7 of 9
The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a patient who is mechanically ventilated. Ensuring that the aaibri-rbf.lcuoimd/ teinstt erface is at the level of the phlebostatic axis, what is the best nursing action?
Correct Answer: C
Rationale: The correct answer is C because placing the patient with the head of the bed elevated 30 degrees is the best position for obtaining an accurate PAOP reading. Elevating the head of the bed helps to align the phlebostatic axis with the atrium, ensuring an accurate measurement of PAOP. This position reduces the impact of hydrostatic pressure on the reading. Options A and D are incorrect because the supine position and recording during exhalation or just before the increase in pressures during inhalation can lead to inaccurate readings. Option B is incorrect because documenting the average PAOP after three measurements does not address the importance of positioning for accuracy.
Question 8 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 9 of 9
What is true regarding pain and anxiety in the healthy individual? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A because pain and anxiety trigger the sympathetic nervous system's fight-or-flight response, increasing heart rate, blood pressure, and stress hormones to prepare the body for potential danger. This physiological response helps the individual respond to perceived threats. Choices B, C, and D are incorrect because pain and anxiety typically increase stress levels, do not necessarily remove one from harm, and can hinder rather than enhance performance due to distraction and decreased focus.