ATI RN
Critical Care Nursing Questions Questions
Question 1 of 5
A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, 'I had a temperature of 103.9°F (39.9°C) at home.' The nurse’s first action should be to:
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's current vital signs. The nurse's first action should be to gather objective data to assess the patient's condition and determine the urgency of the situation. Vital signs, including temperature, heart rate, blood pressure, and respiratory rate, provide crucial information for the initial assessment. This will help the nurse identify any signs of sepsis, shock, or other serious conditions that require immediate intervention. The other choices are incorrect because: B: Giving acetaminophen without assessing the patient's vital signs and determining the cause of the symptoms could mask important clinical information and delay appropriate treatment. C: While obtaining a urine sample may be necessary later to rule out a urinary tract infection, it is not the most immediate priority in this case. D: Delaying the patient's assessment and care based on estimated wait times is not appropriate when the patient presents with potentially serious symptoms. Immediate evaluation is required in this scenario.
Question 2 of 5
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 3 of 5
Which action is best for the nurse to take to ensure culturally competent care for an alert, terminally ill Filipino patient?
Correct Answer: A
Rationale: The correct answer is A because it promotes patient-centered care by involving the patient and family in decision-making, respecting their autonomy and preferences. This approach acknowledges the importance of cultural beliefs and values in end-of-life care. Choice B undermines patient autonomy by bypassing direct communication with the patient. Choice C assumes all Filipino individuals have the same cultural needs, which is not accurate. Choice D generalizes preferences without considering individual patient needs and wishes. Overall, choice A is the most appropriate as it aligns with the principles of patient-centered care and cultural competence.
Question 4 of 5
The nurse is preparing to provide postmortem care for a patient who has just died. Which action should the nurse take first?
Correct Answer: A
Rationale: Rationale: A: Closing the patient's eyes and placing a pillow under the head is the first step in postmortem care to maintain dignity and prevent airway occlusion. B: Washing the body and changing clothes can be done later and is not the priority. C: Removing medical equipment can wait until after ensuring the patient's comfort. D: Confirming the death certificate is important but not the immediate first step in postmortem care.
Question 5 of 5
The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite?
Correct Answer: A
Rationale: The correct answer is A: Use tweezers to remove any remaining ticks. The first step is to remove the tick to prevent further transmission of any potential pathogens. This is crucial in preventing tick-borne illnesses. Checking vital signs (B) can be done after the tick is removed. Administering doxycycline (C) should be based on guidelines and individual factors. Obtaining information about recent outdoor activities (D) is important but not the immediate priority.