ATI RN
Critical Care Nursing Exam Questions Questions
Question 1 of 5
The intensive care unit (ICU) nurse educator will determine that teaching arterial pressure monitoring to staff nurses has been effective when the nurse:
Correct Answer: B
Rationale: The correct answer is B because positioning the zero-reference stopcock line level with the hemostatic axis ensures accurate arterial pressure monitoring. Placing the stopcock at the hemostatic axis allows for correct measurement of blood pressure without any errors due to height differences. This positioning helps in obtaining precise and reliable readings. A: Balancing and calibrating the monitoring equipment every 2 hours is important for equipment maintenance but does not directly impact the accuracy of arterial pressure monitoring. C: Ensuring the patient is supine with the head of the bed flat is a standard position for arterial pressure monitoring but does not specifically address the correct positioning of the stopcock. D: Rechecking the location of the hemostatic axis when changing the patient's position is essential for maintaining accuracy, but it does not directly relate to the initial correct positioning of the stopcock.
Question 2 of 5
The nurse notes premature ventricular contractions (PVCs) while suctioning a patient’s endotracheal tube. Which action by the nurse is a priority?
Correct Answer: C
Rationale: The correct answer is C: Stop and ventilate the patient with 100% oxygen. This is the priority action because PVCs can lead to life-threatening arrhythmias and inadequate oxygenation. By stopping suctioning and providing 100% oxygen, the nurse ensures proper oxygenation and ventilation, which takes precedence over addressing the dysrhythmia itself. Decreasing suction pressure (choice A) may not address the underlying issue and could potentially harm the patient. Documenting the dysrhythmia (choice B) is important but not as urgent as ensuring adequate oxygenation. Giving antidysrhythmic medications (choice D) should be done under the direction of a healthcare provider and is not the first-line intervention in this situation.
Question 3 of 5
The nurse is caring for a patient receiving continuous norepinephrine (Levophed) IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted?
Correct Answer: B
Rationale: The correct answer is B because a low Mean Arterial Pressure (MAP) indicates inadequate perfusion, which may require adjusting the norepinephrine infusion rate to increase blood pressure. A: A heart rate of 58 beats/minute is within a normal range and may not necessarily indicate a need for adjustment. C: Elevated Systemic Vascular Resistance (SVR) may be an expected response to norepinephrine and does not necessarily indicate a need for adjustment. D: A low Pulmonary Artery Wedge Pressure (PAWP) may indicate fluid volume deficit but does not directly relate to the need for adjusting norepinephrine infusion rate.
Question 4 of 5
The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take next?
Correct Answer: D
Rationale: The correct action is D: Manually ventilate the patient with 100% oxygen. This is crucial to ensure adequate oxygenation and prevent hypoxia. Holding the ET tube can lead to extubation and airway compromise. Activating the rapid response team (A) may delay immediate intervention. Providing reassurance (B) is important but not the priority in this situation. Calling the health care provider (C) to reinsert the tube would also lead to a delay in providing essential respiratory support.
Question 5 of 5
A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most important to discuss with the health care provider before starting the SBT?
Correct Answer: A
Rationale: The correct answer is A: New ST segment elevation is noted on the cardiac monitor. This finding is concerning because it may indicate myocardial ischemia or infarction, which can be exacerbated by the physiological stress of weaning from mechanical ventilation. It is crucial to address any cardiac issues before initiating a spontaneous breathing trial to prevent potential cardiac complications during the weaning process. Explanation for why the other choices are incorrect: B: Enteral feedings being given through an orogastric tube are not contraindicated for starting a spontaneous breathing trial. C: Scattered rhonchi heard when auscultating breath sounds may indicate retained secretions but are not a contraindication for a spontaneous breathing trial. D: The use of HYDROmorphone to treat postoperative pain is not a contraindication for a spontaneous breathing trial unless it is causing respiratory depression, which would need to be addressed separately.