ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 of 5
After the change-of-shift report, which patient should the progressive care nurse assess first?
Correct Answer: D
Rationale: The correct answer is D. The patient receiving IV heparin with a PTT of 98 seconds is at risk for bleeding due to the therapeutic range of 60-80 seconds. Assessing this patient first is crucial to prevent potential bleeding complications. A high PTT indicates the blood is not clotting properly, increasing the risk of bleeding. Prompt assessment and possible adjustment of heparin infusion are needed. A: The patient with a temperature of 101.4°F may have a fever but is not at immediate risk compared to the patient with a high PTT. B: The patient on BiPAP with a respiratory rate of 16 is stable and does not require immediate assessment. C: The patient post-percutaneous coronary intervention needing to void is a routine need and does not require immediate attention compared to the patient with a critical lab value.
Question 2 of 5
When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87°F (30.6°C), which assessment indicates that the nurse should discontinue active rewarming?
Correct Answer: D
Rationale: The correct answer is D. When rewarming a hypothermic patient, the goal is to gradually increase their core temperature. A core temperature of 94°F (34.4°C) is still below the normal range, but it indicates that the rewarming process is working. Shivering (A) is a normal response to rewarming. A decrease in blood pressure (B) may be expected due to peripheral vasodilation during rewarming. Developing atrial fibrillation (C) may be a concern but does not necessarily indicate that rewarming should be discontinued. Therefore, choice D is correct as it signifies progress in the rewarming process.
Question 3 of 5
Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which action should the nurse plan to do first?
Correct Answer: B
Rationale: The correct answer is B: Assist with the intubation of the patient. In this scenario, the patient is unconscious and has ingested a potentially harmful substance. Intubation is the first priority to maintain the patient's airway and ensure adequate oxygenation. This step is crucial in preventing aspiration of gastric contents and securing the patient's respiratory status. Inserting a large-bore orogastric tube (choice A) is not the priority as airway management takes precedence. Preparing a syringe with saline (choice C) is unnecessary at this stage. Giving the first dose of activated charcoal (choice D) should only be done after securing the airway to prevent aspiration.
Question 4 of 5
As the nurse admits a patient with end-stage kidney disease to the hospital, the patient tells the nurse, 'If my heart or breathing stops, I do not want to be resuscitated.' Which action is best for the nurse to take?
Correct Answer: A
Rationale: Step 1: Asking if these wishes have been discussed with the healthcare provider is important to ensure that the patient's wishes are documented and considered in the care plan. Step 2: The healthcare provider needs to be aware of the patient's preferences regarding resuscitation to provide appropriate care. Step 3: This step helps in clarifying the patient's preferences and ensures that the healthcare team follows the patient's wishes. Step 4: Placing a DNR notation without consulting the healthcare provider may not align with the patient's overall care plan and may lead to potential legal and ethical issues. Step 5: Informing the patient about notarized advance directives and designating a person for healthcare decisions are important but not the immediate step needed in this scenario. In summary, choice A is correct as it prioritizes communication with the healthcare provider to ensure the patient's wishes are properly documented and followed. Choices B, C, and D are incorrect because they do not involve confirming the patient's wishes
Question 5 of 5
The son of a dying patient tells the nurse, 'Mother doesn’t respond anymore when I visit. I don’t think she knows that I am here.' Which response by the nurse is appropriate?
Correct Answer: B
Rationale: The correct answer is B because withdrawal is a common psychological response in the dying process. The nurse should explain to the son that his mother's lack of response may be her way of preparing to leave life. This response validates the son's concerns while providing reassurance. Choice A is incorrect because cutting back visits may not address the underlying issue of the mother's withdrawal. Choice C is incorrect because stimulating the mother may not be beneficial or appropriate in this situation. Choice D is incorrect because not all patients experience a lack of awareness at the end of life, and assuming so may not be helpful in this context.