ATI RN
Critical Care Nursing Questions Questions
Question 1 of 9
A patient nearing death experiences increased secretions and noisy breathing. What is the nurse’s priority intervention?
Correct Answer: B
Rationale: The correct answer is B: Administer anticholinergic medications as prescribed. Anticholinergic medications can help dry up secretions and improve breathing in a patient nearing death. This intervention targets the underlying cause of increased secretions. Suctioning (choice A) may provide temporary relief but does not address the root issue. Elevating the head of the bed and repositioning (choice C) can help with comfort but do not directly address the secretions. Restricting oral intake (choice D) may lead to dehydration and discomfort without effectively managing the secretions. Administering anticholinergic medications is the priority as it directly targets the symptom of increased secretions, improving the patient's comfort and quality of life.
Question 2 of 9
A child is receiving maintenance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg of body weight, plus 50 mL/kg per day for each kilogram between 10 and 20. How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg?
Correct Answer: B
Rationale: To calculate the IV fluids for a 19.5 kg child: 1. For the first 10 kg: 1000 mL 2. For the weight between 10-20 kg: (19.5 kg - 10 kg) * 50 mL/kg = 475 mL Total IV fluids = 1000 mL + 475 mL = 1475 mL To convert to mL per hour: 1475 mL / 24 hours = ~61 mL/hr Therefore, the correct answer is B (61 mL/hr). Incorrect Choices: A (24 mL/hr): Incorrect, as it doesn't consider the additional fluids for the weight between 10-20 kg. C (73 mL/hr) and D (58 mL/hr): Incorrect, as these values are not obtained from the correct calculation based on the given formula.
Question 3 of 9
The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment?
Correct Answer: B
Rationale: The correct answer is B: Medication administration. This is the priority because medication administration is time-sensitive and crucial for patient safety. It requires precise timing and cannot be delayed. Tracheostomy tube suctioning (A), colostomy care instruction (C), and client personal hygiene (D) are important nursing activities but can be adjusted within the schedule based on patient needs and acuity levels. Prioritizing medication administration ensures that patients receive their medications on time, preventing adverse events and promoting optimal health outcomes.
Question 4 of 9
Which statement about resuscitation is true?
Correct Answer: D
Rationale: The correct answer is D because it accurately states that withholding "extraordinary" resuscitation is legal and should be based on specified criteria in advance directives and physician orders. This is in line with medical ethics and patient autonomy. A is incorrect because family presence during resuscitation can be beneficial for emotional support and decision-making. B is incorrect as it is still necessary for a physician to document "do not resuscitate" orders even with a healthcare surrogate. C is incorrect as "slow codes" are not ethical and go against the principle of beneficence.
Question 5 of 9
The nurse is caring for a patient receiving peritoneal dialysis. The patient suddenly complains of abdominal pain and chills. The patient’s temperature is elevated. The nurse should
Correct Answer: D
Rationale: Step 1: Abdominal pain, chills, and elevated temperature suggest a serious complication like visceral perforation. Step 2: Peritoneal dialysate return assessment won't address the potential life-threatening issue. Step 3: Checking blood sugar or evaluating neurological status is not relevant to the presenting symptoms. Step 4: Informing the provider of probable visceral perforation is crucial for prompt intervention and further evaluation.
Question 6 of 9
The patient undergoes a cardiac catheterization that requires the use of contrast dyes during the procedure. To detect signs of contrast-induced kidney injury, the nurse should
Correct Answer: B
Rationale: The correct answer is B because evaluating the patient's serum creatinine for up to 72 hours after the procedure is crucial in detecting contrast-induced kidney injury. An increase in serum creatinine levels indicates impaired kidney function due to the contrast dye. This monitoring allows for early detection and intervention to prevent further kidney damage. Choice A is incorrect because a decrease in urine output is a late sign of kidney injury and may not be present in the early stages. Choice C is incorrect as a renal ultrasound is not typically used to detect contrast-induced kidney injury. Choice D is incorrect as postvoid residual volume assessment is not specific to detecting intrarenal injury related to contrast dye use.
Question 7 of 9
The nurse caring for a critically ill patient implements several components of care. What component is an example of the use of evidence-based practice?
Correct Answer: B
Rationale: The correct answer is B because applying an insulin sliding scale method based on research is an example of evidence-based practice. This method is derived from scientific evidence and research studies, ensuring the best outcomes for the patient. The other choices lack the same level of evidence-based rationale: A is based on a protocol, which may not be evidence-based; C is a standard safety practice, not necessarily evidence-based; D is a decision based on hospital policy or practicality, not specifically evidence-based.
Question 8 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 9 of 9
A client has been admitted after experiencing multiple trauma and is intubated and sedated. When the five members of the immediate family arrive, they are anxious, angry, and very demanding. They all speak loudly at once and ask for many services and answers. What is the best nursing response?
Correct Answer: B
Rationale: The correct answer is B: Take them to a private area for initial explanations. This response is the best because it allows the nurse to address the family's concerns in a private and controlled environment. It promotes effective communication and enables the family to express their emotions and receive information without distractions. Choice A is incorrect because asking the family to leave may escalate the situation and not address their needs. Choice C is inappropriate as paging security to remove the family can worsen the family's distress and hinder communication. Choice D is not ideal as leaving the family alone may lead to misunderstandings and increased anxiety. Overall, choice B is the most therapeutic and effective approach in this situation.