ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 of 5
Family assessment can be challenging and each nurse may obtain additional information regarding family structure and dynamics. What is the best way to share this information from shift to shift?
Correct Answer: B
Rationale: The correct answer is B because developing a standardized reporting form for family information that is incorporated into the patient's medical record ensures consistency and accuracy in sharing vital details about family structure and dynamics from shift to shift. This method allows all healthcare providers to access the information easily and update it as needed, promoting continuity of care and comprehensive understanding of the family's needs. Choices A, C, and D are incorrect because: A: Creating an informal family information sheet may lead to inconsistencies in the information shared among healthcare providers and may not be updated regularly. C: Requiring only the charge nurse to have detailed information may result in information silos and lack of accessibility for all team members. D: Discussing family dynamics as part of the change-of-shift report may lead to important details being missed or forgotten, compromising the quality of care provided.
Question 2 of 5
Ideally, by whom and when should an advance directive be developed?
Correct Answer: C
Rationale: Step-by-step rationale for choice C: 1. Advance directives should be made by the patient to reflect their wishes. 2. Developing it before illness ensures clarity and avoids confusion. 3. Patients may not be able to make informed decisions in critical conditions. 4. Family or surrogates may not accurately represent the patient's wishes. Summary: A - Family in critical condition may not know the patient's wishes. B - Hospital admission process may be too late for clear decision-making. D - Healthcare surrogate may not fully understand the patient's preferences.
Question 3 of 5
The nurse uses subtle measures of painful stimuli, such as nailbed pressure to elicit a response from a neurologically impaired patient. By using this meth od rather than nipple pinching, the nurse is exemplifying what ethical principle?
Correct Answer: C
Rationale: The correct answer is C: Nonmaleficence. The nurse is demonstrating nonmaleficence by choosing a less harmful method (nailbed pressure) to assess pain in a neurologically impaired patient, instead of a more painful method (nipple pinching). Nonmaleficence is the ethical principle of avoiding harm or minimizing harm to the patient. In this scenario, the nurse is prioritizing the well-being and comfort of the patient by using a less invasive and painful method to elicit a response. Choices A, B, and D are incorrect because beneficence refers to doing good for the patient, fidelity to being loyal and maintaining trust, and veracity to truthfulness and honesty, none of which directly apply in this situation.
Question 4 of 5
The nurse is caring for a critically ill patient with terminal cancer. The monitor alarms and shows ventricular tachycardia. The patient does not have a “do not resuscitate” order written on the chart. What is the appropriate nursing action?
Correct Answer: D
Rationale: The correct answer is D: Initiate CPR and call a code. In this scenario, the patient is critically ill with ventricular tachycardia, a life-threatening arrhythmia. Since there is no "do not resuscitate" order, the appropriate nursing action is to initiate CPR immediately to attempt to restore the patient's cardiac function and circulation. Calling a code will ensure that a team of healthcare providers can respond promptly with necessary interventions. Options A and B involve unnecessary delays in potentially life-saving interventions. Option C is incorrect as withholding intubation can compromise the patient's airway and oxygenation. Thus, option D is the most appropriate action to prioritize the patient's safety and well-being in this critical situation.
Question 5 of 5
Warning signs that can assist the critical care nurse in reco gnizing that an ethical dilemma may exist include which of the following? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A because when family members are confused about the patient's condition or treatment, it can indicate a lack of communication or understanding, leading to a potential ethical dilemma. This confusion may result in conflicting views on what is best for the patient, potentially leading to disagreements and ethical conflicts. Choice B is incorrect because although family conflict can lead to ethical dilemmas, it is not a direct warning sign that an ethical dilemma exists. Choice C is incorrect because the family asking not to inform the patient about treatment is more related to communication preferences rather than a clear indication of an ethical dilemma. Choice D is incorrect because a deteriorating patient condition, while concerning, does not directly signal an ethical dilemma unless there are specific ethical considerations involved in the treatment decisions.