ATI RN
Critical Care Nursing Questions Questions
Question 1 of 9
All of the patient’s children are distressed by the possibility of removing life-support treatments. The child who is most upset tells the nurse, “T his is the same as killing! I thought you were supposed to help!” What response would the nur se provide to the family?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Acknowledges the child's distress and concerns. 2. Explains the concept of allowing natural death after serious injuries. 3. Helps the family understand the ethical and medical reasoning behind removing life support. 4. Shows empathy and provides education to address misconceptions. Summary of other choices: B: Incorrect - Avoids addressing the family's concerns and provides a vague response. C: Incorrect - Contains a typo and does not directly address the child's distress or misunderstanding. D: Incorrect - Irrelevant response that does not address the ethical dilemma at hand.
Question 2 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 3 of 9
The critical care environment is often stressful to a criticalalbyir bil.clo pma/tteiset nt. Identify stressors that are commonly stressful for the critically ill patient. (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Alarms that sound from various devices. In the critical care environment, alarms often indicate changes in the patient's condition, causing stress. Bright fluorescent lighting (B) may be bothersome but not directly related to patient stress. Lack of day-night cues (C) may disrupt sleep patterns but is not a direct stressor. Sounds from the mechanical ventilator (D) are essential for patient care and not inherently stressful.
Question 4 of 9
What is the most common cause of a pulmonary embolus?
Correct Answer: B
Rationale: The correct answer is B: A deep vein thrombosis from lower extremities. Deep vein thrombosis (DVT) is the most common cause of a pulmonary embolus as a blood clot can dislodge from the veins, travel to the lungs, and block blood flow. An amniotic fluid embolus (Choice A) occurs during childbirth and is rare as a cause of pulmonary embolism. A fat embolus (Choice C) typically occurs after a long bone fracture and is more likely to cause issues in the lungs. Vegetation from an infected central venous catheter (Choice D) can cause septic pulmonary embolism, but it is not as common as DVT.
Question 5 of 9
The nurse returns from the cardiac catheterization laboratory with a patient following insertion of a pulmonary artery catheter and assists in transferring th e patient from the stretcher to the bed. Prior to obtaining a cardiac output, which action is m ost important for the nurse to complete?
Correct Answer: B
Rationale: The correct answer is B: Zero reference the transducer system at the phlebostatic axis. This is the most important action before obtaining a cardiac output because zero referencing ensures accurate pressure readings. The phlebostatic axis is the level of the atria when the patient is supine, and zeroing at this point minimizes errors in pressure measurements. Choice A is incorrect because documenting a pulmonary artery catheter occlusion pressure is not the priority at this stage. Choice C is incorrect as inflating the balloon with air should be done after zero referencing. Choice D is incorrect as injecting normal saline into the port is not necessary before zero referencing.
Question 6 of 9
Which patient should the nurse notify the organ procureme nt organization (OPO) to evaluate for possible organ donation?
Correct Answer: A
Rationale: The correct answer is A because the patient is a 36-year-old with a Glasgow Coma Scale score of 3 and no activity on electroencephalogram, indicating severe brain injury and likely irreversible neurological damage. This patient meets the criteria for potential organ donation as they are neurologically devastated. Choice B is incorrect because the patient's condition is related to stroke and atrial fibrillation, not severe brain injury that would make them a candidate for organ donation. Choice C is incorrect because although the patient has a brain injury and a lower Glasgow Coma Scale score, the history of a reversible cause (ovarian cancer metastasis) and a higher GCS score compared to choice A make this patient less suitable for organ donation evaluation. Choice D is incorrect as the patient's diabetic and cardiovascular history does not suggest severe brain injury that would qualify for organ donation.
Question 7 of 9
The American Nurses Credential Center Magnet Recognition Program supports many actions to ensure that nurses are engaged and empowered to participate in ethical decision making. Which of the following would assist nurses in being involvabeirdb .icnom r/etesset arch studies?
Correct Answer: A
Rationale: Rationale: A: Education on protection of human subjects is crucial for nurses to understand ethical principles when conducting research studies. It ensures compliance with ethical guidelines and protection of research participants. B: Participation of staff nurses on ethics committees is not directly related to conducting research studies and may not specifically involve protection of human subjects. C: Written descriptions of how nurses participate in ethics programs do not necessarily focus on research studies and may not cover the specific ethical considerations required in research. D: Written policies and procedures related to response to ethical issues are important but may not provide the necessary knowledge on protection of human subjects for conducting research studies.
Question 8 of 9
When performing an initial pulmonary artery occlusion pr essure (PAOP), what are the best nursing actions? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change. This is because inflating the balloon within this time frame allows for accurate measurement of PAOP without causing complications like pulmonary edema. Noting the waveform change helps in determining the accurate pressure reading. Explanation of why other choices are incorrect: B: Inflating the balloon with air and recording the volume necessary is not a recommended practice as it can lead to inaccurate readings and potential harm to the patient. C: Maintaining the balloon inflated for 8 hours following insertion is unnecessary and could lead to complications such as vascular damage or thrombosis. D: Zero referencing and leveling the transducer at the phlebostatic axis are important steps but not directly related to performing an initial PAOP measurement.
Question 9 of 9
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.