ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 of 9
The nurse is caring for a critically ill patient who can speak. The nurse notices that the patient is demonstrating behaviors indicative of anxiety but is silent. What nursing strategy would give the nurse the most information about the patients feelings?
Correct Answer: B
Rationale: The correct answer is B because asking the patient to share his or her internal dialogue can provide direct insight into the patient's thoughts and feelings, allowing the nurse to address specific anxieties. This approach promotes open communication and understanding. Choice A focuses on providing information but may not directly address the patient's feelings. Choice C is unrelated to addressing the patient's anxiety. Choice D addresses pain control, which is important but not directly related to exploring the patient's emotions. Therefore, option B is the most effective strategy for gaining insight into the patient's feelings in this scenario.
Question 2 of 9
The nurse observes that an elderly woman, whose granddaughter has been admitted to theICU, is struggling to manage her two great-grandsons, who are toddlers, in the waiting room. What is the most likely explanation for the womans inability to manage the children in this situation?
Correct Answer: B
Rationale: The correct answer is B: She is in the exhaustion stage of the general adaptation syndrome to stress. Rationale: 1. In the exhaustion stage, the body's resources are depleted due to prolonged stress, leading to fatigue and reduced ability to cope. 2. The elderly woman is likely experiencing high levels of stress due to her granddaughter's critical condition. 3. Managing toddlers while dealing with the emotional distress of a loved one in the ICU can be overwhelming, causing exhaustion. 4. This explanation aligns with the symptoms of fatigue and difficulty managing the children observed by the nurse. Summary: A: Incorrect. Senility is a cognitive condition unrelated to the stress of the situation. C: Incorrect. Assuming a caregiver role can be stressful, but it does not explain the observed exhaustion. D: Incorrect. Macular degeneration affects vision, not the ability to manage stress and children.
Question 3 of 9
The family of your critically ill patient tells you that they h ave not spoken with the physician in over 24 hours and they have some questions that they w ant clarified. During morning rounds, you convey this concern to the attending intensivist and arrange for her to meet with the family at 4:00 PM in the conference room. Which com petency of critical care nursing does this represent?
Correct Answer: C
Rationale: The correct answer is C: Collaboration with patients, families, and team members. By addressing the family's concern about lack of communication with the physician and arranging a meeting between the intensivist and the family, the nurse is demonstrating collaboration skills in facilitating communication and ensuring the family's questions are addressed. This competency emphasizes the importance of working together with patients, families, and the healthcare team to provide optimal care. Incorrect choices: A: Advocacy and moral agency in solving ethical issues - While advocacy is important in nursing, in this scenario, the focus is on communication and collaboration rather than ethical issues. B: Clinical judgment and clinical reasoning skills - Although these skills are crucial in critical care nursing, the situation described does not primarily involve clinical judgment but rather communication and collaboration. D: Facilitation of learning for patients, families, and team members - While patient education is important, the main focus of the scenario is on addressing the family's concerns and facilitating communication, rather than educational aspects.
Question 4 of 9
When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patient’s temperature is 101.8°F. What should the nurse plan to do next?
Correct Answer: B
Rationale: The correct answer is B: Discontinue the catheter and culture the tip. The patient's symptoms indicate a possible catheter-related infection. Discontinuing the catheter will prevent further infection spread. Culturing the tip will identify the specific pathogen causing the infection, guiding appropriate antibiotic therapy. Choice A is incorrect because giving analgesics alone will not address the underlying infection. Choice C is incorrect as changing the flush system is not a priority when infection is suspected. Choice D is incorrect as checking the site more frequently does not address the need for immediate action to address the infection.
Question 5 of 9
What is a minimally acceptable urine output for a patient weighing 75 kg?
Correct Answer: C
Rationale: The correct answer is C (80 mL/hour) because the minimum acceptable urine output for a patient is approximately 0.5-1 mL/kg/hour. For a 75 kg patient, this equates to 37.5-75 mL/hour. Therefore, an output of 80 mL/hour is within this range and is considered minimally acceptable. A: Less than 30 mL/hour is incorrect because it is below the recommended range for a 75 kg patient. B: 37 mL/hour is close to the lower end of the acceptable range, but it is not the minimum acceptable output. D: 150 mL/hour is above the recommended range and would be considered excessive for a 75 kg patient.
Question 6 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 7 of 9
The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the patient’s urine output has been less than 20 mL/hour for the past 2 hours. The patient’s blood pressure is 100/60 mm Hg, and the pulse is 110 beats/min. Previously, the pulse was 90 beats/min with a blood pressure of 120/80 mm Hg. The nurse should
Correct Answer: A
Rationale: The correct answer is A: contact the provider and expect a prescription for a normal saline bolus. The patient is showing signs of hypovolemia with decreased urine output, low blood pressure, and elevated heart rate. This indicates inadequate perfusion and potential hypovolemic shock. Administering a normal saline bolus will help restore intravascular volume and improve perfusion. Waiting for the provider to make rounds (option B) could delay necessary intervention. Continuing to evaluate urine output for 2 more hours (option C) is not appropriate given the patient's current condition. Ignoring the urine output (option D) is dangerous as it could lead to further complications.
Question 8 of 9
When providing palliative care, the nurse must keep in mind that the family may include which of the following? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Unmarried life partners of same sex. When providing palliative care, it's crucial to recognize and respect diverse family structures. Unmarried life partners of the same sex may form a significant familial bond, requiring support and involvement in care decisions. This choice aligns with the principles of inclusivity and non-discrimination in palliative care. Incorrect choices: B: Unmarried life partners of the opposite sex - This choice is incorrect as it limits the definition of family to only opposite-sex partners, excluding same-sex couples. C: Roommates - While roommates may provide support, they do not necessarily have the same level of emotional and decision-making involvement as family members or life partners. D: Close friends - While close friends can be important sources of support, they do not necessarily have the same legal or emotional ties as a life partner.
Question 9 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.