ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 of 9
Following an earthquake, patients are triaged by emergency medical personnel and are transported to the emergency department (ED). Which patient will the nurse need to assess first?
Correct Answer: A
Rationale: The correct answer is A: A patient with a red tag. In triage, red tags indicate patients with life-threatening injuries who require immediate attention. The nurse must assess this patient first to provide necessary interventions. Patients with blue tags are considered urgent but stable, black tags are deceased or beyond help, and yellow tags are for delayed treatment. Assessing the red-tagged patient first ensures prompt care for those in critical condition.
Question 2 of 9
Upon entering the room of a patient with a right radial arte rial line, the nurse assesses the waveform to be slightly dampened and notices blood to bea bbirabc.ckoemd/te ustp into the pressure tubing. What is the best action by the nurse?
Correct Answer: B
Rationale: The correct answer is B: Disconnect the flush system from the arterial line catheter. This action is necessary to prevent air from entering the patient's bloodstream, which can lead to air embolism. By disconnecting the flush system, the nurse stops the flow of air and ensures patient safety. Checking the inflation volume of the pressurized bag (A) is not the immediate concern in this situation. Zero referencing the transducer system (C) is unrelated to the issue of air entering the arterial line. Reducing the number of stopcocks in the flush system tubing (D) does not address the immediate risk of air embolism.
Question 3 of 9
In assessing a patient, the nurse understands that what sym ptomology is an early sign of hypoxemia?
Correct Answer: D
Rationale: Step 1: Restlessness is an early sign of hypoxemia due to the body's response to low oxygen levels. Step 2: Restlessness occurs as the body tries to increase oxygen intake. Step 3: Other choices are incorrect because clubbing and cyanosis are late signs, while hypotension is not a specific early sign of hypoxemia.
Question 4 of 9
A patient is admitted to the hospital with multiple trauma aabnirdb .ceoxmte/tensst ive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vas cular resistance of 3000 dynes/sec/cm5, and a hematocrit of 20%. The nurse anticip ates administration of which the following therapies or medications?
Correct Answer: C
Rationale: The correct answer is C: Dobutamine infusion. In this scenario, the patient is experiencing hypovolemic shock due to significant blood loss, resulting in low blood pressure, tachycardia, and low cardiac output. Dobutamine is a positive inotropic agent that increases cardiac contractility and output, helping to improve tissue perfusion. Blood transfusion (A) is a common intervention for hypovolemic shock, but in this case, the patient's hematocrit is low, indicating dilutional anemia rather than acute blood loss, so addressing the cardiac output is more urgent. Furosemide (B) is a diuretic that would exacerbate the hypovolemia and worsen the patient's condition. Dopamine (D) is a vasopressor that primarily increases blood pressure, but in this case, the patient's low cardiac output is the main concern, making dobutamine a more appropriate choice.
Question 5 of 9
Which intervention about visitation in the critical care unit is true?
Correct Answer: C
Rationale: The correct answer is C because individualized visitation meets the unique needs of patients and family members, promoting holistic care and emotional support. Choice A is incorrect as strictly restricted visiting hours may hinder family involvement in care. Choice B is incorrect as children can provide comfort and support. Choice D is incorrect as unrestricted visiting may disrupt patient rest and care routines.
Question 6 of 9
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 7 of 9
The nurse is caring for a terminally ill patient who has chosen palliative care. Which goal should the nurse prioritize when planning care?
Correct Answer: B
Rationale: The correct answer is B: Manage the patient's pain and symptoms. In palliative care, the primary goal is to provide comfort and improve quality of life for terminally ill patients. Managing pain and symptoms is crucial in achieving this goal. By addressing pain and symptoms, the nurse can help enhance the patient's comfort and well-being. Other choices are incorrect because palliative care focuses on improving quality of life rather than curing the underlying disease (A), prolonging life expectancy (C), or primarily addressing family concerns (D). Prioritizing pain and symptom management aligns with the holistic approach of palliative care.
Question 8 of 9
A young man has just arrived at the ICU from out of town and received news that his girlfriend, who is admitted there, likely only has a few days left to live. Which of the following would be the best approach for the nurse to take in caring for the needs of this young man?
Correct Answer: C
Rationale: The correct answer is C: Suggesting that he meet with the hospital chaplain. This approach is best as it addresses the young man's emotional and spiritual needs during a difficult time. The chaplain can provide comfort, support, and guidance in coping with his girlfriend's situation. This option focuses on holistic care and acknowledges the importance of emotional well-being. A: Recommending that he go home and rest is not the best approach as it dismisses the young man's emotional distress. B: Giving him unrestricted visiting hours with the patient may not be appropriate as it can be overwhelming and may not address his emotional needs effectively. D: Recommending that he ask the doctor to evaluate the patient's pain control measures is important but does not directly address the young man's emotional needs in this situation.
Question 9 of 9
The family of your critically ill patient tells you that they h ave not spoken with the physician in over 24 hours and they have some questions that they w ant clarified. During morning rounds, you convey this concern to the attending intensivist and arrange for her to meet with the family at 4:00 PM in the conference room. Which com petency of critical care nursing does this represent?
Correct Answer: C
Rationale: The correct answer is C: Collaboration with patients, families, and team members. By addressing the family's concern about lack of communication with the physician and arranging a meeting between the intensivist and the family, the nurse is demonstrating collaboration skills in facilitating communication and ensuring the family's questions are addressed. This competency emphasizes the importance of working together with patients, families, and the healthcare team to provide optimal care. Incorrect choices: A: Advocacy and moral agency in solving ethical issues - While advocacy is important in nursing, in this scenario, the focus is on communication and collaboration rather than ethical issues. B: Clinical judgment and clinical reasoning skills - Although these skills are crucial in critical care nursing, the situation described does not primarily involve clinical judgment but rather communication and collaboration. D: Facilitation of learning for patients, families, and team members - While patient education is important, the main focus of the scenario is on addressing the family's concerns and facilitating communication, rather than educational aspects.