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
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
A patient’s status deteriorates and mechanical ventilation i s now required. The pulmonologist wants the patient to receive 10 breaths/min from the ventilaabtirobr.c bomu/tt ewst ants to encourage the patient to breathe spontaneously in between the mechanical breaths at his own tidal volume. This mode of ventilation is referred to by what term?
Correct Answer: C
Rationale: Rationale: 1. Intermittent Mandatory Ventilation (IMV) allows the patient to breathe spontaneously between the preset mechanical breaths. 2. It provides a set number of breaths per minute while allowing the patient to initiate additional breaths at their own tidal volume. 3. IMV is a partial ventilatory support mode, providing a balance between controlled and spontaneous breathing. 4. Assist/Control Ventilation (A) provides full support with every breath initiated by the patient or the ventilator. 5. Controlled Ventilation (B) does not allow for spontaneous breaths by the patient. 6. Positive End-Expiratory Pressure (D) is a separate mode focusing on maintaining positive pressure at the end of expiration, not providing breaths.
Question 4 of 9
The nurse is caring for a patient who has an intra-aortic balloon pump in place. Which action should be included in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Measure the patient’s urinary output every hour. This is crucial because monitoring urinary output is essential in assessing the patient’s renal function and the effectiveness of the intra-aortic balloon pump in improving cardiac output. Hourly measurement helps in early detection of any changes that may indicate complications. A: Positioning the patient supine at all times is not necessary and can lead to complications. B: Avoiding the use of anticoagulant medications is not appropriate as they are often necessary to prevent clot formation around the balloon pump. D: Providing a massive range of motion for all extremities is not recommended for a patient with an intra-aortic balloon pump as it can dislodge the device or cause harm.
Question 5 of 9
The nurse is caring for four patients on the progressive car e unit. Which patient is at greatest risk for developing delirium?
Correct Answer: C
Rationale: The correct answer is C, the 86-year-old postoperative from colonic resection. This patient is at the greatest risk for delirium due to being elderly, having undergone surgery, and having a history of being from a nursing home. These factors contribute to an increased susceptibility to delirium. A: The 36-year-old with alcohol withdrawal may be at risk for delirium tremens, but the older age of the patient in choice C places them at higher risk. B: The 54-year-old with an elevated creatinine level postoperative is at risk for complications, but age and history of nursing home placement increase the risk for delirium in choice C. D: The 95-year-old with community-acquired pneumonia is at risk for delirium, but the combination of age, surgery, and nursing home history in choice C presents a greater risk.
Question 6 of 9
Identify which substances in the glomerular filtrate would indicate a problem with renal function. (Select all that apply.)
Correct Answer: A
Rationale: The presence of protein in the glomerular filtrate indicates a problem with renal function because in healthy kidneys, proteins are retained in the blood and not filtered into the urine. If protein is found in the filtrate, it suggests damage to the glomerular filtration barrier. Sodium, creatinine, and red blood cells are normally present in the filtrate and are not indicative of renal dysfunction. Sodium is freely filtered and reabsorbed, creatinine is a waste product of muscle metabolism excreted by the kidneys, and a small number of red blood cells may be filtered due to their small size. Therefore, protein in the glomerular filtrate is the most specific indicator of renal dysfunction.
Question 7 of 9
The removal of plasma water and some low–molecular weight particles by using a pressure or osmotic gradient is known as
Correct Answer: D
Rationale: Ultrafiltration is the correct answer because it involves the removal of plasma water and low-molecular weight particles by using a pressure or osmotic gradient. During ultrafiltration, the pressure gradient pushes the fluid through a semipermeable membrane, separating the substances based on their molecular size. This process allows for the selective removal of unwanted substances while retaining essential components. Dialysis (choice A) involves the removal of waste products from the blood, but it does not specifically target plasma water and low-molecular weight particles. Diffusion (choice B) is the passive movement of particles from an area of higher concentration to an area of lower concentration and is not specific to the removal of plasma water. Clearance (choice C) refers to the rate at which a substance is removed from the blood and does not involve the mechanism of pressure or osmotic gradient utilized in ultrafiltration.
Question 8 of 9
When providing palliative care, the nurse must keep in mind that the family may include which of the following? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Unmarried life partners of same sex. When providing palliative care, it's crucial to recognize and respect diverse family structures. Unmarried life partners of the same sex may form a significant familial bond, requiring support and involvement in care decisions. This choice aligns with the principles of inclusivity and non-discrimination in palliative care. Incorrect choices: B: Unmarried life partners of the opposite sex - This choice is incorrect as it limits the definition of family to only opposite-sex partners, excluding same-sex couples. C: Roommates - While roommates may provide support, they do not necessarily have the same level of emotional and decision-making involvement as family members or life partners. D: Close friends - While close friends can be important sources of support, they do not necessarily have the same legal or emotional ties as a life partner.
Question 9 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.