ATI RN
Critical Care Nursing Questions and Answers PDF Questions
Question 1 of 9
Sleep often is disrupted for critically ill patients. Which nu rsing intervention is most appropriate to promote sleep and rest?
Correct Answer: A
Rationale: The correct answer is A: Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between intervals. This is the most appropriate intervention as medication timings can significantly impact sleep patterns of critically ill patients. Adjusting medication times can help synchronize rest periods, promoting uninterrupted sleep. Choice B is incorrect as encouraging constant conversation can disrupt sleep. Choice C is incorrect as the television noise can be stimulating and hinder rest. Choice D is incorrect as leaving the lights on can disrupt the patient's circadian rhythm and negatively impact sleep quality.
Question 2 of 9
A patient requires neuromuscular blockade (NMB) as part of treatment of refractive increased intracranial pressure. The nursing care for this patient includes which interventions? (Select all that apply.)
Correct Answer: C
Rationale: The correct answer is C: Ensuring that deep vein thrombosis prophylaxis is initiated. When a patient requires neuromuscular blockade for increased intracranial pressure, they are likely immobile, which increases the risk of deep vein thrombosis (DVT). Initiating DVT prophylaxis, such as compression stockings or anticoagulant therapy, helps prevent blood clot formation. Choice A is incorrect because sedatives can mask signs of neurologic deterioration in this patient population. Choice B is incorrect as it promotes activities that may increase intracranial pressure and could be harmful. Choice D, while important for overall patient care, is not directly related to the specific nursing interventions required for a patient receiving neuromuscular blockade for increased intracranial pressure.
Question 3 of 9
A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent?
Correct Answer: A
Rationale: The correct answer is A: Obtain the permission of the custodial parent for the surgery. In this scenario, the client is a minor (16 years old), which means they are not legally able to provide informed consent for medical procedures. The custodial parent holds legal responsibility for the minor's healthcare decisions. Thus, obtaining the permission of the custodial parent is crucial to ensure valid informed consent. Choice B is incorrect because the non-custodial parent's consent may not be legally required if the custodial parent is available to provide consent. Choice C is incorrect because obtaining consent should precede any administration of medications. Choice D is incorrect as the stepfather's consent may not hold legal weight unless designated as a legal guardian.
Question 4 of 9
A 45-year-old postsurgical patient is on a ventilator in the critical care unit has been tolerating the ventilator well and has not required any sedation. The apbairtbi.ecnomt /bteesct omes tachycardic and hypertensive with a respiratory rate that has increased to 28 breaths/min. The ventilator is set on synchronized intermittent mandatory ventilation (SIMV ) at a rate of 10 breaths/min. The patient has been suctioned recently via existing endotracheal tube until airway is clear. When the patient responds appropriately to the nurse’s command s, what should be the nurse’s priority intervention?
Correct Answer: A
Rationale: The correct answer is A: Assessing the patient's level of pain. In this situation, the patient's tachycardia, hypertension, and increased respiratory rate could be indicative of pain. By assessing the patient's pain level, the nurse can address any discomfort the patient may be experiencing, which could be contributing to these physiological responses. Summary of other choices: B: Decreasing the SIMV rate on the ventilator - This is not the priority intervention as the patient's symptoms are more likely related to pain rather than the ventilator settings. C: Providing sedation as ordered - Sedation is not the priority in this case as the patient has been tolerating the ventilator well without requiring sedation. D: Suctioning the patient again - Since the airway has been recently cleared, suctioning again is not necessary at this point and would not address the underlying cause of the patient's symptoms.
Question 5 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 6 of 9
The sister of a patient in the ICU has been at the patients bedside non-stop for 48 hours. The nurse suggests to her that she return home to rest. Which of the following is the proper rationale for the nurse making such a suggestion?
Correct Answer: D
Rationale: The correct answer is D: The sister needs to maintain her own health during this time. It is essential for the sister to take care of her own health and well-being to be able to provide the best support to the patient. Continuous stress and lack of rest can negatively impact her ability to support the patient effectively. Encouraging her to rest will ensure she remains physically and mentally well to continue supporting the patient in the long run. Incorrect Choices: A: The sister is in the way of the health care providers - This is incorrect as the primary concern is the well-being of the sister and her ability to provide support. B: The patient may become annoyed by her continual presence - This is not the main reason for suggesting the sister to rest, as the focus is on her own health. C: The patient will recover more easily in peace and quiet - While peace and quiet can be beneficial for the patient, the main focus here is on the sister's well-being.
Question 7 of 9
The nurse is assessing the patient’s pain using the Critical Care Pain Observation Tool (CPOT). Which of the following assessments would indicate the greatest likelihood of pain and need for nursing intervention?
Correct Answer: B
Rationale: The correct answer is B: Fighting the ventilator. This behavior indicates the patient is experiencing discomfort and struggling against the ventilator, suggesting a high likelihood of pain. The CPOT assesses pain through behaviors like grimacing, vocalization, and muscle tension, which are all present when a patient is fighting the ventilator. Absence of vocal sounds (Choice A) does not necessarily indicate pain as some patients may be silent even when in pain. Moving legs in bed (Choice C) could be due to restlessness rather than pain. Relaxed muscles in upper extremities (Choice D) do not reflect pain as the CPOT focuses on behaviors indicating discomfort.
Question 8 of 9
The patient is diagnosed with acute kidney injury and has been getting dialysis 3 days per week. The patient complains of general malaise and is tachypneic. An arterial blood gas shows that the patient’s pH is 7.19, with a PCO of 30 mm Hg and a bicarbonate level of 13 mEq/L. The nurse prepares to
Correct Answer: C
Rationale: The correct answer is C: administer intravenous sodium bicarbonate. In this case, the patient has metabolic acidosis with a low pH and low bicarbonate levels. Administering sodium bicarbonate can help correct the acidosis by increasing the bicarbonate levels and improving the pH. This treatment is essential to address the underlying metabolic imbalance. Choice A is incorrect because administering morphine would not address the root cause of the acidosis and could potentially worsen the respiratory status. Choice B is incorrect as intubation and mechanical ventilation are not indicated solely based on the acid-base imbalance. Choice D is also incorrect as canceling the dialysis session would not address the metabolic acidosis and could potentially worsen the patient's condition.
Question 9 of 9
Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should follow in resolving the conflict?
Correct Answer: D
Rationale: The correct answer is D: Deal with issues and not personalities. This guideline is important because it focuses on resolving the conflict based on the actual problem at hand, rather than personal biases or emotions. By addressing the issues causing the argument, the nurse can help the UAPs find a fair and logical solution. A: Requiring the UAPs to reach a compromise may not address the root cause of the conflict and could lead to further disagreements. B: Weighing the consequences is important but may not be as effective in resolving the conflict as directly addressing the issues. C: Encouraging humor may temporarily diffuse the situation but may not lead to a lasting resolution.