A patient in the ICU is complaining that he is not sleeping well at night because of anxiety. Which of the following would be the most helpful intervention for the nurse to make?

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Critical Care Nursing Questions Questions

Question 1 of 9

A patient in the ICU is complaining that he is not sleeping well at night because of anxiety. Which of the following would be the most helpful intervention for the nurse to make?

Correct Answer: C

Rationale: Rationale: C: Providing the patient with 5 minutes of effleurage (gentle massage) and minimizing disruptions is the most helpful intervention. Effleurage can help reduce anxiety and promote relaxation, improving sleep quality. Minimizing disruptions creates a conducive environment for sleep. A: Providing a bath after REM sleep may disrupt the patient's sleep cycle, worsening anxiety. B: Increasing pain medication may not address the root cause of anxiety and could lead to dependency or side effects. D: Monitoring brain waves with polysomnography is an invasive procedure not typically indicated for managing anxiety-related sleep issues.

Question 2 of 9

The nurse understands that a patient being cared for in a critical care unit experiences anacute stress response. What nursing action best demonstrates understanding of the physiological parts of the initial stress response?

Correct Answer: C

Rationale: The correct answer is C: Treatment for elevated blood pressure. In the initial stress response, the body releases adrenaline and cortisol, leading to increased heart rate and blood pressure. Treating elevated blood pressure is crucial to prevent complications like heart attack or stroke. Adequate pain control (A) and intravenous sedation (B) may help manage symptoms but do not directly address the physiological response to stress. Ignoring an elevated glucose level (D) is not recommended as stress can impact blood sugar levels. Treatment for elevated blood pressure directly targets the physiological response to stress, making it the best nursing action in this scenario.

Question 3 of 9

A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats per minute. What action should the nurse implement next?

Correct Answer: D

Rationale: The correct answer is D: Administer the medication. Atenolol is a beta-blocker used to reduce heart rate and blood pressure. In this scenario, the client's apical pulse of 65 beats per minute is within the normal range for a client taking atenolol after a myocardial infarction. Therefore, the nurse should proceed with administering the medication as prescribed to help maintain the client's heart rate and blood pressure within the therapeutic range. A: Measuring the blood pressure is important but not the immediate next step as the client's heart rate is within the normal range. B: Reassessing the apical pulse is unnecessary since it is already within the normal range for a client on atenolol. C: Notifying the healthcare provider is not indicated as there are no signs of concern with the client's heart rate at 65 bpm.

Question 4 of 9

A patients family is exhibiting increasingly impaired coping as the patients condition deteriorates. The nurse asks the family to state the biggest concern from their perspective.What is the most important rationale for this question?

Correct Answer: C

Rationale: The correct answer is C because asking the family to state their biggest concern clarifies the nurse's understanding of the current family needs. This step allows the nurse to assess the specific areas where the family may require support or assistance, leading to more tailored interventions. By identifying the primary concern, the nurse can better address the family's emotional, informational, or practical needs. Choice A is incorrect because the question is not solely about active listening; it serves a deeper purpose of assessment. Choice B is incorrect as the question goes beyond validating knowledge to understanding emotional and practical needs. Choice D is incorrect because the question focuses on identifying concerns rather than defining the degree of understanding.

Question 5 of 9

A nurse has been working as a staff nurse in the surgical inabteirbn.scoivme/t ecsat re unit for 2 years and is interested in certification. Which credential would be most applicable for her to seek?

Correct Answer: C

Rationale: The correct answer is C: CCRN. The nurse works in a surgical unit, making CCRN (Critical Care Registered Nurse) the most applicable credential as it focuses on critical care nursing, which is relevant to the nurse's current practice. ACNPC (Acute Care Nurse Practitioner Certification) and PCCN (Progressive Care Certified Nurse) are not suitable as they are more focused on advanced practice or progressive care respectively, not directly related to surgical units. CCNS (Clinical Nurse Specialist Certification) is not the best choice as it is more geared towards advanced practice roles in specific clinical specialties, not general staff nursing.

Question 6 of 9

The nurse cares for a patient with lung cancer in a home hospice program. Which action by the nurse is most appropriate?

Correct Answer: B

Rationale: The correct answer is B because in a home hospice program, it is essential for the nurse to provide holistic care that includes addressing the patient's emotional and psychological needs. Encouraging the patient to discuss past life events and their meaning can help them process emotions, find closure, and improve their quality of life. This approach aligns with the principles of palliative care, which focus on enhancing comfort and well-being. Choice A is incorrect because discussing cancer risk factors and lifestyle modifications may not be relevant or beneficial for a patient in a hospice program. Choice C is incorrect because chemotherapy and radiation are typically not part of hospice care, which focuses on comfort rather than curative treatments. Choice D is incorrect because a thorough head-to-toe assessment multiple times a week may not be necessary or appropriate for a patient in a hospice program.

Question 7 of 9

During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next?

Correct Answer: B

Rationale: Rationale: The correct action is to observe the patient's respiratory effort next. This step ensures that the patient's breathing remains stable and adequate. If respiratory effort is compromised, immediate intervention is required. Checking for bilateral pulses (A) is important but comes after ensuring respiratory status. Checking level of consciousness (C) is also crucial but not as immediate as monitoring breathing. Examining for external bleeding (D) is important but not the priority when airway and breathing are already determined to be clear.

Question 8 of 9

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement?

Correct Answer: C

Rationale: The correct answer is C: "I should drink sports drinks when working outside in hot weather." This statement is correct because hypotension and elevated temperature could indicate dehydration and electrolyte imbalance due to excessive sweating in hot weather. Drinking sports drinks can help replenish electrolytes lost through sweating and prevent dehydration. Incorrect choices: A: Taking salt tablets can lead to an imbalance in electrolytes and worsen the condition. B: Acetaminophen can lower fever but does not address dehydration or electrolyte imbalance. D: Moving to a cool environment when feeling confused is important but does not address the underlying issue of dehydration and electrolyte imbalance.

Question 9 of 9

A nurse is on a committee that is trying to reduce the occurrence of hospital-acquired infections in the ICU. Her role is to conduct research to find which interventions have been shown to be most effective in reducing these infections. She consults many different sources and finds conflicting information. Which of the following sources should she consider the most authoritative?

Correct Answer: B

Rationale: The correct answer is B: A meta-analysis of randomized controlled trials in the American Journal of Nursing. 1. Meta-analyses provide a comprehensive overview of multiple studies, increasing the reliability of the findings. 2. Randomized controlled trials are considered the gold standard in research design for assessing intervention effectiveness. 3. The American Journal of Nursing is a reputable source in the field of nursing, ensuring the credibility of the study. 4. By synthesizing data from various trials, the meta-analysis can offer a more robust and generalizable conclusion compared to a single trial or qualitative studies. Incorrect choices: A: AACN expert panel report - Expert opinions may vary and lack the empirical evidence provided by research studies. C: A systematic review of qualitative studies in the Journal of Advanced Nursing - Qualitative studies may provide valuable insights but may not offer concrete evidence on intervention effectiveness like quantitative studies. D: A single randomized controlled trial in the American Journal of Critical Care - Single trials may not capture the full picture and

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