ATI RN
Critical Care Nursing Questions Questions
Question 1 of 9
Positive end-expiratory pressure (PEEP) is a mode of ventaiblairbto.croym /atessst istance that produces which of the following conditions
Correct Answer: D
Rationale: The correct answer is D because positive end-expiratory pressure (PEEP) is a mode of ventilation where pressure is maintained in the lungs at the end of expiration. This helps prevent alveolar collapse and improves oxygenation. Option A is incorrect because PEEP does not deliver a full preset tidal volume with each breath initiation. Option B is incorrect because tidal volume in PEEP is not solely determined by the patient's ability to generate negative pressure. Option C is incorrect because in PEEP, breaths are delivered irrespective of the patient's respiratory drive.
Question 2 of 9
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next?
Correct Answer: B
Rationale: Rationale: The correct action is to observe the patient's respiratory effort next. This step ensures that the patient's breathing remains stable and adequate. If respiratory effort is compromised, immediate intervention is required. Checking for bilateral pulses (A) is important but comes after ensuring respiratory status. Checking level of consciousness (C) is also crucial but not as immediate as monitoring breathing. Examining for external bleeding (D) is important but not the priority when airway and breathing are already determined to be clear.
Question 3 of 9
A hospice patient is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. Which statement, if made by the nurse to the patient’s family member, is most appropriate?
Correct Answer: B
Rationale: The correct answer is B because an increase in heart rate and respiratory rate can be a normal response before body system functions decrease in a hospice patient. This is known as a compensatory mechanism as the body tries to maintain oxygenation. Choice A is incorrect because symptoms may not always continue to increase until death. Choice C is incorrect as it implies a reflex response, which may not be the case. Choice D is incorrect as an improvement in the patient's condition is unlikely in a hospice setting.
Question 4 of 9
Which of the following are accepted nonpharmacological approaches to managing pain and/or anxiety in critically ill patients? (Select all that apply.)
Correct Answer: A
Rationale: Step 1: Environmental manipulation involves adjusting factors like lighting, noise levels, and room temperature to create a soothing environment, which can help reduce pain and anxiety. Step 2: By controlling the physical surroundings, patients may feel more comfortable and relaxed, leading to improved pain management and reduced anxiety levels. Step 3: Explanations of monitoring equipment and guided imagery are not directly related to environmental changes that can impact pain and anxiety. Step 4: Music therapy, while beneficial for some patients, is not categorized as environmental manipulation.
Question 5 of 9
The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite?
Correct Answer: A
Rationale: The correct answer is A: Use tweezers to remove any remaining ticks. The first step is to remove the tick to prevent further transmission of any potential pathogens. This is crucial in preventing tick-borne illnesses. Checking vital signs (B) can be done after the tick is removed. Administering doxycycline (C) should be based on guidelines and individual factors. Obtaining information about recent outdoor activities (D) is important but not the immediate priority.
Question 6 of 9
Which intervention is appropriate to assist the patient to co pe with admission to the critical care unit?
Correct Answer: B
Rationale: The correct answer is B: Explaining all procedures in easy-to-understand terms. This intervention is appropriate as it helps reduce the patient's anxiety by providing clear information about what to expect during their stay in the critical care unit. This promotes a sense of control and understanding, which can positively impact the patient's coping mechanisms. A: Allowing unrestricted visiting by several family members at one time may overwhelm the patient and interfere with their rest and recovery. C: Providing back massage and mouth care may be beneficial but may not directly address the patient's need for information and understanding. D: Turning down the alarm volume on the cardiac monitor may provide a more comfortable environment but does not address the patient's emotional and psychological needs related to coping with admission to the critical care unit.
Question 7 of 9
A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, 'I had a temperature of 103.9°F (39.9°C) at home.' The nurse’s first action should be to:
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's current vital signs. The nurse's first action should be to gather objective data to assess the patient's condition and determine the urgency of the situation. Vital signs, including temperature, heart rate, blood pressure, and respiratory rate, provide crucial information for the initial assessment. This will help the nurse identify any signs of sepsis, shock, or other serious conditions that require immediate intervention. The other choices are incorrect because: B: Giving acetaminophen without assessing the patient's vital signs and determining the cause of the symptoms could mask important clinical information and delay appropriate treatment. C: While obtaining a urine sample may be necessary later to rule out a urinary tract infection, it is not the most immediate priority in this case. D: Delaying the patient's assessment and care based on estimated wait times is not appropriate when the patient presents with potentially serious symptoms. Immediate evaluation is required in this scenario.
Question 8 of 9
A nurse is weaning a 68-kg male patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped?
Correct Answer: C
Rationale: The correct answer is C because a respiratory rate of 32 breaths/min indicates increased work of breathing, which could be a sign of respiratory distress. In a patient being weaned from mechanical ventilation, an elevated respiratory rate suggests that the patient may not be able to sustain adequate ventilation on their own. This warrants stopping the weaning protocol to prevent respiratory failure. Choice A is incorrect because a heart rate of 97 beats/min is within normal range for an adult. Choice B is incorrect because an oxygen saturation of 93% is acceptable for a patient with COPD. Choice D is incorrect because a tidal volume of 450 mL is adequate for a patient weaning from mechanical ventilation.
Question 9 of 9
The family of a critically ill patient has asked to discuss organ donation with the patient’s nurse. When preparing to answer the family’s questions, th e nurse understands which concern(s) most often influence a family’s decision to donate? (Select all that apply.)
Correct Answer: A
Rationale: Rationale for Correct Answer A: Donor disfigurement influences on funeral care. Families often consider the impact of organ donation on the appearance of their loved one during funeral arrangements. This concern can significantly influence their decision to donate. Incorrect Answers: B: Fear of inferior medical care provided to donor. This is not a common concern as medical care for donors is typically of high quality. C: Age and location of all possible organ recipients. While important, this is not a primary concern for families when deciding on organ donation. D: Concern that donated organs will not be used. Families are generally more concerned about the impact on their loved one's appearance post-donation rather than the utilization of organs.