ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 of 9
The family members of a critically ill, 90-year-old patient bring in a copy of the patient’s living will to the hospital, which identifies the patient’s wiasbhireb.sc orme/gteasrt ding health care. The nurse discusses the contents of the living will with the patient’s physician. This is an example of implementation of which of the AACN Standards of Pr ofessional Performance?
Correct Answer: C
Rationale: The correct answer is C: Considers factors related to safe patient care. The scenario involves the nurse discussing the patient's living will with the physician, which is essential for ensuring safe patient care by following the patient's preferences. This aligns with the AACN standard of considering factors related to safe patient care, as the nurse is actively involving all relevant parties in decision-making to provide care that is in line with the patient's wishes. Explanation of why other choices are incorrect: A: Acquires and maintains current knowledge of practice - While important, this choice does not directly relate to the scenario where the focus is on safe patient care through communication and collaboration. B: Acts ethically on behalf of the patient and family - While ethics are important, the scenario is more about following the patient's wishes as outlined in the living will rather than making ethical decisions. D: Uses clinical inquiry and integrates research findings in practice - While valuable in nursing practice, this choice does not directly apply to the scenario where
Question 2 of 9
The nurse is assessing the critically ill patient for delirium . The nurse recognizes which characteristics that indicate hyperactive delirium? (Select aabllir bt.hcaomt /atepstp ly.)
Correct Answer: A
Rationale: The correct answer is A: Agitation. In hyperactive delirium, patients often exhibit restlessness, agitation, and hyperactivity. This behavior is a key characteristic indicating hyperactive delirium. Apathy (B), biting (C), and hitting (D) are not typically associated with hyperactive delirium. Apathy may be seen in hypoactive delirium, while biting and hitting are not specific indicators of delirium subtypes. Therefore, the correct choice is A as it aligns with the typical presentation of hyperactive delirium.
Question 3 of 9
The critical care nurse is responsible for monitoring the patient receiving continuous renal replacement therapy (CRRT). In doing so, the nurse should
Correct Answer: B
Rationale: The correct answer is B because assessing the hemofilter every 6 hours for clotting is essential in ensuring the effectiveness of CRRT. Clotting can obstruct blood flow, leading to treatment inefficiency and potential harm to the patient. This step helps the nurse to promptly address any clotting issues and prevent complications. A: Assessing that the blood tubing is warm to the touch is not a standard practice for monitoring CRRT and does not provide relevant information about the treatment's effectiveness. C: Covering the dialysis lines to protect them from light is not a priority in monitoring CRRT. Light exposure is not a common concern in this context. D: Using clean technique during vascular access dressing changes is important for infection prevention but is not directly related to monitoring the effectiveness of CRRT.
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
A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse should provide the patient with what explanation?
Correct Answer: B
Rationale: The correct answer is B: “This injection is being given to prevent blood clots from forming.” Enoxaparin is an anticoagulant used to prevent blood clots. It is administered through injection, not orally (A). Enoxaparin does not dissolve existing blood clots (C). Contacting the primary care provider to discuss the medication is not necessary in this scenario (D). The correct choice emphasizes the purpose of enoxaparin in preventing new blood clots.
Question 6 of 9
The family members of a critically ill, 90-year-old patient bring in a copy of the patient’s living will to the hospital, which identifies the patient’s wiasbhireb.sc orme/gteasrt ding health care. The nurse discusses the contents of the living will with the patient’s physician. This is an example of implementation of which of the AACN Standards of Pr ofessional Performance?
Correct Answer: C
Rationale: The correct answer is C: Considers factors related to safe patient care. The scenario involves the nurse discussing the patient's living will with the physician, which is essential for ensuring safe patient care by following the patient's preferences. This aligns with the AACN standard of considering factors related to safe patient care, as the nurse is actively involving all relevant parties in decision-making to provide care that is in line with the patient's wishes. Explanation of why other choices are incorrect: A: Acquires and maintains current knowledge of practice - While important, this choice does not directly relate to the scenario where the focus is on safe patient care through communication and collaboration. B: Acts ethically on behalf of the patient and family - While ethics are important, the scenario is more about following the patient's wishes as outlined in the living will rather than making ethical decisions. D: Uses clinical inquiry and integrates research findings in practice - While valuable in nursing practice, this choice does not directly apply to the scenario where
Question 7 of 9
As part of the admission process, the nurse asks several questions about family relationships. The nurse bases these actions on which rationale?
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct: 1. Involving the family in patient care is crucial for holistic care. 2. Assessing family relationships helps identify support systems and potential conflicts. 3. Understanding family dynamics aids in creating a comprehensive care plan. 4. Family involvement can enhance patient outcomes and satisfaction. Summary of incorrect choices: B. Irrelevant, as the focus is on patient-centered care, not just fulfilling an assessment tool. C. Personal curiosity is not a valid reason for assessing family relationships in healthcare. D. Conducting research on family patterns does not directly impact the immediate care of the patient.
Question 8 of 9
Upon entering the room of a patient with a right radial arte rial line, the nurse assesses the waveform to be slightly dampened and notices blood to bea bbirabc.ckoemd/te ustp into the pressure tubing. What is the best action by the nurse?
Correct Answer: B
Rationale: The correct answer is B: Disconnect the flush system from the arterial line catheter. This action is necessary to prevent air from entering the patient's bloodstream, which can lead to air embolism. By disconnecting the flush system, the nurse stops the flow of air and ensures patient safety. Checking the inflation volume of the pressurized bag (A) is not the immediate concern in this situation. Zero referencing the transducer system (C) is unrelated to the issue of air entering the arterial line. Reducing the number of stopcocks in the flush system tubing (D) does not address the immediate risk of air embolism.
Question 9 of 9
The patient’s partner, experiencing anticipatory grieving, tells the nurse, “I don’t see any point in continuing to visit at the bedside, since it’s like I’m not even here.” What is the nurse’s best response to the partner’s statement?
Correct Answer: B
Rationale: The correct answer is B because it acknowledges the partner's feelings while providing information that may help them cope. By stating that unresponsiveness doesn't mean the patient can't hear, the nurse highlights the importance of the partner's presence for emotional support. It encourages the partner to continue visiting, emphasizing their role in providing comfort to the patient. Choice A is incorrect as it dismisses the partner's feelings and lacks empathy. Choice C is incorrect as it implies the nurse will only involve the partner if the patient responds, neglecting the partner's emotional needs. Choice D is incorrect as it deflects responsibility from addressing the partner's concerns and suggests involving other family members without addressing the partner's feelings directly.