ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 of 9
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 2 of 9
The nurse is caring for a patient who has a temporary percutaneous dialysis catheter in place. In caring for this patient, the nurse should
Correct Answer: C
Rationale: The correct answer is C because assessing the catheter site for redness and/or swelling is crucial for early detection of infection. Redness and swelling are common signs of infection at the catheter site, which requires prompt intervention. Applying a sterile gauze dressing (choice A) is not necessary for a temporary percutaneous dialysis catheter. Replacing the transparent dressing every 10 days (choice B) is not recommended as it can increase the risk of infection. Using the catheter for drawing blood samples (choice D) is not appropriate as it can introduce contaminants and increase the risk of infection. Regular assessment of the catheter site is essential for early detection and prevention of complications.
Question 3 of 9
Which action is a priority for the nurse to take when the low-pressure alarm sounds for a patient who has an arterial line in the left radial artery?
Correct Answer: C
Rationale: Rationale for Correct Answer (C): When the low-pressure alarm sounds for a patient with an arterial line, the nurse should assess for cardiac dysrhythmias first. This is because a sudden drop in pressure could indicate a serious issue affecting the heart's ability to pump effectively. Identifying and addressing any cardiac dysrhythmias promptly is crucial for patient safety. Summary of Incorrect Choices: A: Fast flush of the arterial line - This would not address the underlying cause of the low-pressure alarm and may not be necessary. B: Check the left hand for pallor - While assessing perfusion is important, it is not the priority when the alarm indicates a potential cardiac issue. D: Rezero the monitoring equipment - While important for accuracy, it is not the priority when the alarm indicates a potential cardiac concern.
Question 4 of 9
The nurse is caring for a mechanically ventilated patient. T he primary care providers are considering performing a tracheostomy because the patienatb iirsb .hcoamv/itensgt difficulty weaning from mechanical ventilation. Related to tracheostomy, the nurse understands which of the following?
Correct Answer: C
Rationale: The correct answer is C: Procedures performed in the operating room are associated with fewer complications. This is because performing a tracheostomy in the operating room allows for better control of the environment, equipment, and expertise of the surgical team. In this setting, the risk of complications such as bleeding, infection, and injury to surrounding structures is minimized. Choices A, B, and D are incorrect: A: Patient outcomes are better if the tracheostomy is done within a week of intubation - This statement is not universally true and depends on individual patient factors. Timing of tracheostomy should be based on the patient's clinical condition and not a set timeline. B: Percutaneous tracheostomy can be done safely at the bedside by the respiratory therapist - While percutaneous tracheostomy can be performed at the bedside, it is typically done by a trained physician or surgeon due to the potential risks and complications involved. D: The greatest risk after a per
Question 5 of 9
The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder?
Correct Answer: A
Rationale: Step 1: Symptoms of weight loss, racing heart rate, and difficulty sleeping are common in hyperthyroidism. Step 2: Presence of moist skin, fine hair, prominent eyes, lid retraction, and staring expression are classic signs of Grave's disease, a type of hyperthyroidism. Step 3: Grave's disease is an autoimmune disorder where the thyroid gland is overactive, leading to excessive production of thyroid hormones. Step 4: Excess thyroid hormones increase metabolic rate, causing weight loss, racing heart rate, and insomnia. Step 5: Therefore, the findings described in the question are consistent with Grave's disease.
Question 6 of 9
What is a minimally acceptable urine output for a patient weighing 75 kg?
Correct Answer: C
Rationale: The correct answer is C (80 mL/hour) because the minimum acceptable urine output for a patient is approximately 0.5-1 mL/kg/hour. For a 75 kg patient, this equates to 37.5-75 mL/hour. Therefore, an output of 80 mL/hour is within this range and is considered minimally acceptable. A: Less than 30 mL/hour is incorrect because it is below the recommended range for a 75 kg patient. B: 37 mL/hour is close to the lower end of the acceptable range, but it is not the minimum acceptable output. D: 150 mL/hour is above the recommended range and would be considered excessive for a 75 kg patient.
Question 7 of 9
A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma?
Correct Answer: D
Rationale: The correct answer is D, Metoprolol tartrate (Lopressor). Metoprolol is a cardioselective beta-blocker that primarily targets beta-1 receptors in the heart, making it less likely to exacerbate asthma compared to non-selective beta-blockers like Propranolol (choice B) and Pindolol (choice C). Carteolol (choice A) is also a non-selective beta-blocker and can potentially worsen asthma symptoms. Metoprolol's selectivity for beta-1 receptors minimizes bronchoconstriction, making it the safest choice for a client with asthma and high blood pressure.
Question 8 of 9
A patient in hospice care is experiencing dyspnea. What is the most appropriate nursing intervention?
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen as prescribed. Dyspnea in a hospice patient often indicates respiratory distress, and administering oxygen can help improve oxygenation and alleviate breathing difficulty. Positioning the patient flat on their back (A) may worsen dyspnea due to increased pressure on the diaphragm. Restricting fluid intake (C) is not appropriate as dehydration can exacerbate respiratory distress. Chest physiotherapy (D) may not be suitable for a hospice patient experiencing dyspnea as it can be physically taxing and may not address the underlying cause effectively.
Question 9 of 9
The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: high Fowler's position. This position promotes optimal lung expansion by allowing the chest to expand fully, improving oxygenation. It also helps reduce the work of breathing. Side lying with the head of the bed elevated (B) may not provide the same level of lung expansion. Sitting in a chair (C) may not be suitable for a patient in acute respiratory failure as it may not provide adequate support for breathing. Supine with the bed flat (D) can worsen respiratory distress by limiting lung expansion.