ATI RN
Critical Care Nursing Questions and Answers PDF Questions
Question 1 of 9
Her urine output for the past 2 hours totaled only 40 mL. She arrived from s urgery to repair an aortic aneurysm 4 hours ago and remains on mechanical ventilation. In the past 2 hours, her heart rate has increased from 80 to 100 beats per minute and he r blood pressure has decreased from 128/82 to 100/70 mm Hg. She is being given an infusaiboirnb .coofm n/toesrtm al saline at 100 mL per hour. Her right atrial pressure through the subclavian cen tral line is low at 3 mm Hg. Her urine is concentrated. Her BUN and creatinine levels have been stable and in normal range. Her abdominal dressing is dry with no indication of bleeding. My assessment suggests that Mrs. P. is hypovolemic and I would like you to consider in creasing her fluids or giving her a fluid challenge. Using the SBAR model for communication, the information the nurse gives about the patient’s history and vital signs is appropriate fo r what part of the model?
Correct Answer: C
Rationale: The correct answer is C: Assessment. In the SBAR communication model, the nurse's information about the patient's history and vital signs falls under the Assessment component. This is because the nurse is providing a detailed evaluation of the patient's current condition based on objective data such as urine output, heart rate, blood pressure, and other key indicators. The nurse is analyzing the situation and forming a judgment that the patient is hypovolemic, indicating a fluid deficit. This assessment is crucial for informing further actions or interventions, such as increasing fluids or providing a fluid challenge. Summary of other choices: A: Situation - This choice would refer to a brief summary of the current situation without detailed analysis or interpretation. B: Background - This choice would involve providing relevant background information about the patient, such as medical history or recent procedures, but not the current assessment of the patient's condition. D: Recommendation - This choice would involve suggesting a course of action or treatment based on the assessment, which comes after
Question 2 of 9
A 15-year-old boy is in the ICU and preparing for an appendectomy. He is clearly anxious and fidgets with his IV constantly. He complains that he doesnt want to be there and he is sick of everyone telling him what to do. What would be the best way for the nurse to address this patients anxiety?
Correct Answer: B
Rationale: The correct answer is B: Offer him the remote to the television. This is the best way to address the patient's anxiety because it provides a distraction and a sense of control, which can help alleviate anxiety. By offering the patient the remote to the television, the nurse is giving him a choice and a way to focus his attention away from his anxiety. This can help him feel more comfortable and empowered in the situation. Choice A is incorrect because using physical restraints can increase the patient's anxiety and sense of helplessness. Choice C, lowering the head of his bed, may provide physical comfort but does not directly address his anxiety. Choice D, explaining the procedure in detail, may further increase his anxiety as it focuses on the surgery rather than addressing his current emotional state.
Question 3 of 9
A patient who is undergoing withdrawal of mechanical ventilation appears anxious and agitated. The patient is on a continuous morphine infusion and has an additional order for lorazepam 1 to 2 mg IV as needed (prn). The patient has received no lorazepam during this course of illness. What is the most appropriate nursing intearbvirbe.ncotmio/tnes tt o control agitation?
Correct Answer: B
Rationale: Step-by-step rationale for why choice B is correct: 1. Midazolam is a benzodiazepine used for sedation and anxiolysis. 2. It acts quickly and has a short duration of action, suitable for acute agitation. 3. Lorazepam (also a benzodiazepine) is in the same drug class, ensuring compatibility. 4. Lorazepam is specifically ordered for this patient, indicating its appropriateness. 5. Administering midazolam addresses the patient's agitation efficiently and safely. Summary of why other choices are incorrect: A: Fentanyl is an opioid analgesic, not ideal for managing agitation. C: Increasing morphine infusion can exacerbate sedation or respiratory depression. D: Paralytic agents are used for neuromuscular blockade, not agitation control.
Question 4 of 9
The nurse is concerned about the risk of alcohol withdraw al syndrome in a 45-year-old postoperative patient. Which statement indicates an unders tanding of management of this patient?
Correct Answer: D
Rationale: The correct answer is D because initiating the alcohol withdrawal protocol shows an understanding of managing a patient at risk for alcohol withdrawal syndrome. This protocol involves carefully monitoring the patient's symptoms, providing appropriate medications, and ensuring a safe environment. Option A is incorrect as it downplays the seriousness of alcohol withdrawal. Option B is incorrect as there are assessment tools available for identifying alcohol withdrawal. Option C is incorrect as pain management should be tailored to the individual's needs, not necessarily lessened due to alcohol withdrawal risk.
Question 5 of 9
What is the nurse’s priority intervention when a terminally ill patient reports severe breakthrough pain?
Correct Answer: B
Rationale: The correct answer is B: Administer a prescribed PRN opioid analgesic. This is the priority intervention because severe breakthrough pain requires immediate relief, and opioids are the most effective for managing severe pain in terminally ill patients. Warm compresses (A) may provide some comfort but do not address the underlying pain. Reassessing pain after 2 hours (C) delays necessary relief. Distraction techniques (D) are not appropriate for severe breakthrough pain as they do not directly address the pain itself. Administering the prescribed opioid analgesic promptly is crucial for providing timely and effective pain management in this situation.
Question 6 of 9
The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 12 5 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO ) of 90% on a 50% venturi mask. 2 Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pres sure (PAOP) of 3 mm Hg. The nurse questions which of the following primary health care provider’s order?
Correct Answer: D
Rationale: The correct answer is D: Administer furosemide 20 mg intravenously. In this scenario, the patient is hypotensive with a low cardiac output, low CVP, and low PAOP, indicating cardiogenic shock. Administering furosemide, a diuretic, can worsen the patient's condition by further decreasing preload. This can lead to a decrease in cardiac output and exacerbate the shock state. The other options are more appropriate: A: Titrate supplemental oxygen to achieve a SpO > 94% - Correct, as improving oxygenation is essential in cardiogenic shock. B: Infuse 500 mL 0.9% normal saline over 1 hour - Correct, as fluid resuscitation may be necessary to improve perfusion. C: Obtain arterial blood gas and serum electrolytes - Correct, as these tests provide valuable information about the patient's oxygenation and electrolyte balance.
Question 7 of 9
The patient is in the critical care unit and will receive dialysis this morning. The nurse will (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A because evaluating morning lab results is crucial to monitor the patient's condition before dialysis. Abnormal results may impact the dialysis treatment plan. Option B is incorrect as administering antihypertensive medications is not directly related to dialysis. Option C is incorrect as assessing the dialysis access site is the responsibility of the dialysis team. Option D is incorrect as weighing the patient is not typically done immediately before dialysis.
Question 8 of 9
The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Remove the patient's rings first. This is crucial to prevent constriction and swelling due to potential allergic reactions or inflammation from bee stings. Removing rings allows for proper circulation and prevents complications like compartment syndrome. Ice packs (B) can be applied after removing the rings to reduce swelling. Calamine lotion (C) can provide relief for itching but is not as urgent as ring removal. Diphenhydramine (D) can be given later for systemic allergic reactions but should not take precedence over removing the rings.
Question 9 of 9
Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?
Correct Answer: C
Rationale: The correct answer is C because a respiratory rate of 32 breaths/minute indicates increased work of breathing, which could be due to secretions that need to be suctioned. High respiratory rate may suggest inadequate oxygenation and ventilation. Oxygen saturation of 93% (choice A) is within an acceptable range and does not necessarily indicate the need for suctioning. Time since last suctioning (choice B) should be considered but is not as immediate an indication as an increased respiratory rate. Occasional audible expiratory wheezes (choice D) may be indicative of other respiratory issues but do not directly indicate the need for suctioning.