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 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 3 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 4 of 9
The nurse is preparing for insertion of a pulmonary artery acbairtbh.ceotme/rte (sPt AC). During insertion of the catheter, what are the priority nursing actions? (Select all that apply.)
Correct Answer: B
Rationale: The correct answer is B: Ensure that a sterile field is maintained during the insertion procedure. This is the priority nursing action because maintaining a sterile field is crucial to prevent infection during the invasive procedure. The nurse must follow strict aseptic technique to reduce the risk of introducing bacteria into the patient's bloodstream. All other choices are incorrect: A: Addressing the patient's anxiety is important but not the priority during the insertion procedure. C: Inflating the balloon is a specific action that should be performed by the physician, not the nurse. D: While monitoring the patient's cardiac rhythm is important, ensuring the sterile field takes precedence to prevent complications.
Question 5 of 9
The critical care environment is stressful to the patient. Which interventions assist in reducing this stress? (Select all that apply.)
Correct Answer: A
Rationale: Correct Answer: A. Adjust lighting to promote normal sleep-wake cycles. Rationale: 1. Adjusting lighting can help regulate the patient's circadian rhythm, promoting better sleep and reducing stress. 2. Normal sleep-wake cycles are crucial for overall well-being and healing in a critical care setting. 3. Proper lighting can also create a more calming environment for the patient. Summary of Incorrect Choices: B. Providing clocks, calendars, and personal photos can be overwhelming for a stressed patient. C. Talking about other patients may increase anxiety and breach patient confidentiality. D. Telling the day and time of routine interventions may disrupt the patient's sense of time and add to stress.
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 nurse has identified an increase in medication errors in the critical care unit over the past several months. What aspect of medication procedures should be evaluated first?
Correct Answer: A
Rationale: The correct answer is A: Adherence to procedures by nursing staff. This should be evaluated first because medication errors are often caused by human factors such as staff not following proper procedures. By assessing adherence, the root cause of errors can be identified and addressed. Choice B: Clarity of interdisciplinary communication may contribute to errors but doesn't directly address staff adherence to procedures. Choice C: Number of new employees could be a factor, but focusing on adherence to procedures is more crucial. Choice D: Changes in administration procedures may impact errors, but evaluating staff adherence is more immediate and directly related to errors.
Question 8 of 9
After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse include in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Apply external cooling device. Therapeutic hypothermia is a treatment used to protect the brain after cardiac arrest by lowering the body temperature. The nurse should use external cooling devices, such as cooling blankets or ice packs, to achieve and maintain the desired temperature. This method allows for precise temperature control and monitoring. Checking mental status every 15 minutes (choice B) is not the priority as maintaining the temperature is crucial. Avoiding sedative medications (choice C) may be necessary to accurately assess the patient's neurological status. Rewarming if the temperature is <91°F (32.8°C) (choice D) is incorrect as the goal is to maintain hypothermia for a specific duration before gradual rewarming.
Question 9 of 9
The nurse is counseling a family about end-of-life care for their loved one. Which statement by the family indicates understanding of palliative care?
Correct Answer: A
Rationale: The correct answer is A because palliative care indeed focuses on providing relief from pain and other symptoms, enhancing quality of life for patients with serious illnesses. This aligns with the essence of palliative care, which is to provide holistic support to improve comfort and well-being. The other choices are incorrect: B is wrong because palliative care does not aim to cure the underlying disease but rather to alleviate suffering; C is incorrect as palliative care can be initiated earlier in the disease trajectory, not just during the final days; and D is inaccurate because patients can continue receiving treatments alongside palliative care to manage symptoms and improve their quality of life.