ATI RN
Critical Care Nursing Questions Questions
Question 1 of 9
A patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first?
Correct Answer: C
Rationale: The correct answer is C: Body temperature. In a patient who has fallen through the ice, hypothermia is a major concern due to exposure to cold water. Assessing body temperature first is crucial to determine the severity of hypothermia and guide immediate interventions. Heart rate, breath sounds, and level of consciousness can be affected by hypothermia but are secondary assessments. Assessing body temperature is the priority to address the most life-threatening issue first.
Question 2 of 9
A nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped?
Correct Answer: C
Rationale: The correct answer is C because a respiratory rate of 32 breaths/min indicates increased work of breathing, which could be a sign of respiratory distress. In a patient being weaned from mechanical ventilation, an elevated respiratory rate suggests that the patient may not be able to sustain adequate ventilation on their own. This warrants stopping the weaning protocol to prevent respiratory failure. Choice A is incorrect because a heart rate of 97 beats/min is within normal range for an adult. Choice B is incorrect because an oxygen saturation of 93% is acceptable for a patient with COPD. Choice D is incorrect because a tidal volume of 450 mL is adequate for a patient weaning from mechanical ventilation.
Question 3 of 9
The nurse caring for a mechanically ventilated patient note s the high pressure alarm sounding but cannot quickly identify the cause of the alarm. The nurasbeir bn.cootme/ste stht e patient’s oxygen saturation is decreasing and heart rate and respiratory rate are increasing. What is the nurse’s priority action?
Correct Answer: B
Rationale: The correct answer is B. The nurse's priority is to ensure the patient's safety and well-being. Calling the rapid response team will allow for immediate assessment by a team of healthcare professionals to address the deteriorating condition. This step takes precedence over troubleshooting the ventilator or manually ventilating the patient. Asking for a new ventilator (A) or manually ventilating the patient (D) does not address the urgent need for a comprehensive assessment and intervention. Continuing to troubleshoot the alarm (C) can delay critical interventions needed for the patient's worsening condition. Thus, calling the rapid response team is the most appropriate action to address the escalating clinical situation promptly.
Question 4 of 9
Which treatment can be used to dissolve a thrombus that is lodged in the pulmonary artery?
Correct Answer: D
Rationale: The correct answer is D: Thrombolytics. Thrombolytics are medications that can dissolve blood clots, making them effective in treating a thrombus lodged in the pulmonary artery. They work by activating the body's natural clot-dissolving system. Aspirin (A) is an antiplatelet drug and may prevent further clot formation but cannot dissolve an existing thrombus. Embolectomy (B) is a surgical procedure to remove a clot and is invasive, usually reserved for cases where thrombolytics are contraindicated. Heparin (C) is an anticoagulant that prevents clot formation but does not dissolve existing clots like thrombolytics do.
Question 5 of 9
Slow continuous ultrafiltration is also known as isolated ultrafiltration and is used to
Correct Answer: A
Rationale: The correct answer is A because slow continuous ultrafiltration removes excess plasma water in cases of volume overload by applying a pressure gradient across a semipermeable membrane. This process helps to achieve fluid balance without removing solutes. Choice B is incorrect because convection is not the primary mechanism of slow continuous ultrafiltration. Choice C is incorrect as dialysate is not added in slow continuous ultrafiltration. Choice D is incorrect as slow continuous ultrafiltration does not combine all three processes of ultrafiltration, convection, and dialysis.
Question 6 of 9
The family of a critically ill patient has asked to discuss organ donation with the patient’s nurse. When preparing to answer the family’s questions, th e nurse understands which concern(s) most often influence a family’s decision to donate? (Select all that apply.)
Correct Answer: A
Rationale: Rationale for Correct Answer A: Donor disfigurement influences on funeral care. Families often consider the impact of organ donation on the appearance of their loved one during funeral arrangements. This concern can significantly influence their decision to donate. Incorrect Answers: B: Fear of inferior medical care provided to donor. This is not a common concern as medical care for donors is typically of high quality. C: Age and location of all possible organ recipients. While important, this is not a primary concern for families when deciding on organ donation. D: Concern that donated organs will not be used. Families are generally more concerned about the impact on their loved one's appearance post-donation rather than the utilization of organs.
Question 7 of 9
A patient who has been declared brain dead is considered a potential organ donor. In order to proceed with donation, the nurse must understand that applicable concept?
Correct Answer: B
Rationale: The correct answer is B because after brain death is confirmed, maintaining perfusion and oxygenation of organs is crucial to ensure their viability for donation. This process allows organs to be retrieved in optimal condition during the operation. Choice A is incorrect because a signed donor card is not a legal mandate for organ retrieval. Choice C is incorrect as the healthcare proxy's consent is typically required for organ donation. Choice D is incorrect because life support is not immediately withdrawn upon brain death confirmation; instead, organ preservation measures are initiated.
Question 8 of 9
The nurse is assessing pain levels in a critically ill patient . The nurse recognizes that which patient action as indicatin g the greatest level of pain?
Correct Answer: C
Rationale: Correct Answer: C (Grimacing) Rationale: 1. Grimacing is a universal nonverbal sign of pain. 2. It involves facial muscles, indicating a high level of discomfort. 3. Brow lowering and eyelid closing are subtle signs, less indicative of severe pain. 4. Staring may signify concentration, not necessarily pain. Summary: Grimacing is the correct choice as it directly correlates with pain intensity, unlike the other options which are less specific or relevant indicators of severe pain.
Question 9 of 9
Which intervention is appropriate to assist the patient to co pe with admission to the critical care unit?
Correct Answer: B
Rationale: The correct answer is B: Explaining all procedures in easy-to-understand terms. This intervention is appropriate as it helps reduce the patient's anxiety by providing clear information about what to expect during their stay in the critical care unit. This promotes a sense of control and understanding, which can positively impact the patient's coping mechanisms. A: Allowing unrestricted visiting by several family members at one time may overwhelm the patient and interfere with their rest and recovery. C: Providing back massage and mouth care may be beneficial but may not directly address the patient's need for information and understanding. D: Turning down the alarm volume on the cardiac monitor may provide a more comfortable environment but does not address the patient's emotional and psychological needs related to coping with admission to the critical care unit.