ATI RN
Critical Care Nursing Cardiac Questions Questions
Question 1 of 9
assessment, the patient is restless, heart rate has increased to 110 beats/min, respirat ions are 36 breaths/min, and blood pressure is 156/98 mm Hg. The cardiac monitor shows sin us tachycardia with 10 premature ventricular contractions (PVCs) per minute. Pulmonary artery pressures are elevated. The nurse suctions the patient and obtains pink, frothy secretio ns. Loud crackles are audible throughout lung fields. The nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. In comambirubn.ciocma/tteinstg with the physician, which statement indicates the nurse understands what is likely occurring with the patient?
Correct Answer: B
Rationale: The correct answer is B: “My assessment indicates potential fluid overload.” The patient is showing signs of fluid overload, such as increased heart rate, respiratory rate, elevated blood pressure, pulmonary artery pressures, frothy secretions, and crackles in lung fields. These symptoms suggest fluid is accumulating in the lungs, causing pulmonary congestion. This can lead to impaired gas exchange and respiratory distress. The nurse's recognition of these signs is crucial for prompt intervention to prevent further complications. Other choices are incorrect because there are no indications of a myocardial infarction, PVCs compromising cardiac output, or a hypertensive crisis based on the given information.
Question 2 of 9
A 20-year-old patient arrives in the emergency department (ED) several hours after taking 25 to 30 acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?
Correct Answer: A
Rationale: The correct answer is A: Give N-acetylcysteine (Mucomyst). N-acetylcysteine is the antidote for acetaminophen overdose. It helps replenish glutathione, which is depleted by acetaminophen metabolism. This prevents liver damage. Choice B, chelation therapy, is not indicated for acetaminophen overdose. Choice C, oxygen therapy, is not directly related to acetaminophen overdose treatment. Choice D, drinking water, will not address the overdose and may not be safe in high doses. Therefore, the best course of action is to administer N-acetylcysteine to prevent liver damage in acetaminophen overdose.
Question 3 of 9
To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to:
Correct Answer: D
Rationale: The correct answer is D because using an end-tidal CO2 monitor is the most reliable method to confirm correct endotracheal tube placement in the trachea. This method detects exhaled CO2, indicating proper tube placement in the trachea. It is a quick and efficient way to confirm placement without delay, reducing the risk of complications. A: Auscultating for bilateral breath sounds is not as reliable because breath sounds may be heard even if the tube is misplaced. B: Obtaining a portable chest x-ray is not the best initial action as it takes time and delays confirming tube placement. C: Observing chest movement may not provide conclusive evidence of proper tube placement and can lead to misinterpretation. In summary, using an end-tidal CO2 monitor is the most accurate and efficient method to verify correct endotracheal tube placement compared to the other options.
Question 4 of 9
The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces th e risk of catheter-related bloodstream infection (CRBSI)?
Correct Answer: A
Rationale: The correct answer is A: Review daily the necessity of the central venous catheter. This action reduces the risk of CRBSI by promoting early removal of unnecessary catheters, which is a key strategy in preventing infections. Unnecessary catheters increase the risk of infection due to prolonged exposure to the patient's skin flora and possible contamination during insertion. Reviewing daily ensures the catheter is only kept when necessary, minimizing the duration of catheter use and reducing the chances of infection. Summary of other choices: B: Cleansing the insertion site daily with isopropyl alcohol is important for maintaining skin integrity but does not directly reduce the risk of CRBSI. C: Changing the pressurized tubing system and flush bag daily is important for maintaining catheter patency but does not directly reduce the risk of CRBSI. D: Maintaining a pressure of 300 mm Hg on the flush bag is important for proper catheter function but does not directly reduce the risk of CR
Question 5 of 9
A patient is declared brain dead and a do not resuscitate (DNR) order is put in place. The nurse caring for the patient does not agree with this manne r of care but does not express any concerns to the charge nurse. The nurse’s feeling that the p atient is being killed will likely create what response for this nurse?
Correct Answer: C
Rationale: The correct answer is C: Moral distress. In this scenario, the nurse is experiencing conflicting moral values between the decision made for the patient and their own beliefs. This internal conflict leads to moral distress, a common response when healthcare professionals feel unable to act in accordance with their ethical beliefs. This can lead to emotional turmoil, frustration, and moral residue. A: A sense of abandonment is incorrect because the nurse is still caring for the patient, so there is no physical abandonment. B: Increased family stress is incorrect as the nurse's internal conflict does not directly impact family stress. D: A sense of negligence is incorrect as negligence implies failure to provide proper care, which is not the case here.
Question 6 of 9
A new nurse has recently joined the ICU from a different hospital, which had a much stricter policy regarding visiting hours. She expresses concern about the impact of open visiting hours on patient well-being. Which of the following would be the best explanation for the purpose of open visiting hours? Select all that apply.
Correct Answer: B
Rationale: The correct answer is B: To strengthen the relationship between the family and health care provider. Rationale: 1. Open visiting hours encourage family involvement in care, fostering a partnership between healthcare providers and families. 2. Family support can positively impact patient outcomes and satisfaction. 3. It allows families to be updated on the patient's condition and involved in decision-making. 4. Strengthening the relationship can lead to better communication and trust between all parties. Summary of Incorrect Choices: A: Open visiting hours may disrupt rest and quiet, but the primary purpose is not to provide rest. C: Open visiting hours do not aim to control the number of visitors but rather encourage family involvement. D: While open visiting hours may not provide an entirely undisturbed environment, the focus is on improving family-provider relationships.
Question 7 of 9
The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse plots the child's weight on the growth chart and notes that the child's weight is in the 95th percentile for the child's height. What action should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Question the type and quantity of foods eaten in a typical day. When a child's weight is in the 95th percentile for their height, it indicates possible overweight or obesity. To address this, the nurse should assess the child's dietary habits to identify any unhealthy eating patterns contributing to excess weight. By questioning the type and quantity of foods eaten, the nurse can provide appropriate guidance on nutrition and healthy eating habits. Summary: B: Encouraging additional snacks may further contribute to weight gain and is not recommended without knowing the current eating habits. C: Recommending a high intake of whole milk may increase calorie intake and potentially worsen the weight concern. D: Assessing for signs of poor nutrition, such as a pale appearance, is important but not directly addressing the weight concern in this scenario.
Question 8 of 9
In determining the glomerular filtration rate (GFR) or creatinine clearance, a 24-hour urine is obtained. If a reliable 24-hour urine collection is not possible,
Correct Answer: D
Rationale: The correct answer is D because when a reliable 24-hour urine collection is not possible, a standardized formula can be used to estimate GFR. The Cockcroft-Gault equation or the Modification of Diet in Renal Disease (MDRD) equation are commonly used formulas to estimate GFR based on serum creatinine levels, age, gender, and race. These formulas provide a reasonable estimation of kidney function in the absence of a 24-hour urine collection. Choice A is incorrect because there are alternative methods available to estimate GFR. Choice B is incorrect because BUN alone is not sufficient to accurately determine renal function. Choice C is incorrect because an elevated BUN/creatinine ratio is not a direct measure of GFR and may be influenced by factors other than kidney function, such as hydration status or liver function.
Question 9 of 9
The nurse is managing a donor patient six hours prior to th e scheduled harvesting of the patient’s organs. Which assessment finding requires imme diate action by the nurse?
Correct Answer: B
Rationale: The correct answer is B. The patient's pH of 7.30 indicates acidosis, PaCO2 of 38 mm Hg is low, and HCO3 of 16 mEq/L is also low, suggesting metabolic acidosis. This finding requires immediate action as untreated acidosis can lead to serious complications. Choice A (morning serum blood glucose of 128 mg/dL) is within normal range and does not require immediate action. Choice C (pulmonary artery temperature of 97.8°F) is a normal temperature and does not require immediate action. Choice D (central venous pressure of 8 mm Hg) is within normal range and does not require immediate action.