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
As the nurse admits a patient with end-stage kidney disease to the hospital, the patient tells the nurse, 'If my heart or breathing stops, I do not want to be resuscitated.' Which action is best for the nurse to take?
Correct Answer: A
Rationale: Step 1: Asking if these wishes have been discussed with the healthcare provider is important to ensure that the patient's wishes are documented and considered in the care plan. Step 2: The healthcare provider needs to be aware of the patient's preferences regarding resuscitation to provide appropriate care. Step 3: This step helps in clarifying the patient's preferences and ensures that the healthcare team follows the patient's wishes. Step 4: Placing a DNR notation without consulting the healthcare provider may not align with the patient's overall care plan and may lead to potential legal and ethical issues. Step 5: Informing the patient about notarized advance directives and designating a person for healthcare decisions are important but not the immediate step needed in this scenario. In summary, choice A is correct as it prioritizes communication with the healthcare provider to ensure the patient's wishes are properly documented and followed. Choices B, C, and D are incorrect because they do not involve confirming the patient's wishes
Question 3 of 9
A 53-year-old, 80-kg patient is admitted to the cardiac sur gical intensive care unit after cardiac surgery with the following arterial blood gas (ABG ) levels. What is the nurse’s interpretation of these values? pH 7.4 PaCO 40 mm Hg Bicarbonate 24 mEq/L PaO 95 mm Hg O saturation 97% Respirations 20 breaths per minute
Correct Answer: C
Rationale: The correct interpretation is C: Normal ABG values. 1. pH is within the normal range of 7.35-7.45. 2. PaCO2 is 40 mm Hg, within the normal range of 35-45 mm Hg. 3. Bicarbonate is 24 mEq/L, within the normal range of 22-26 mEq/L. 4. PaO2 is 95 mm Hg, within the normal range of 80-100 mm Hg. 5. Oxygen saturation is 97%, which is normal. 6. Respirations are also within the normal range at 20 breaths per minute. Overall, all values fall within the normal range, indicating a well-maintained acid-base balance. Other choices are incorrect because there are no abnormalities that would suggest compensated metabolic acidosis, metabolic alkalosis, or respiratory acidosis based on the given ABG values.
Question 4 of 9
The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder?
Correct Answer: A
Rationale: Step 1: Symptoms of weight loss, racing heart rate, and difficulty sleeping are common in hyperthyroidism. Step 2: Presence of moist skin, fine hair, prominent eyes, lid retraction, and staring expression are classic signs of Grave's disease, a type of hyperthyroidism. Step 3: Grave's disease is an autoimmune disorder where the thyroid gland is overactive, leading to excessive production of thyroid hormones. Step 4: Excess thyroid hormones increase metabolic rate, causing weight loss, racing heart rate, and insomnia. Step 5: Therefore, the findings described in the question are consistent with Grave's disease.
Question 5 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 6 of 9
A nurse who plans care based on the patient’s gender, ethn ai bc iri bt .y co, ms /p tei sr ti tuality, and lifestyle is said to demonstrate what focus?
Correct Answer: C
Rationale: The correct answer is C: Responding to diversity. By considering the patient's gender, ethnicity, spirituality, and lifestyle, the nurse is focusing on responding to diversity in patient care. This approach acknowledges and respects the unique characteristics and backgrounds of individual patients, leading to more culturally competent and effective care. Choice A: Becoming a moral advocate does not directly relate to considering diversity in patient care. It involves standing up for ethical principles and values in healthcare. Choice B: Facilitating all forms of learning is not specific to addressing diversity in patient care. It pertains to promoting education and understanding in various learning styles. Choice D: Using effective clinical judgment is important in nursing practice but does not specifically address the focus on diversity in patient care. It pertains to making sound decisions based on clinical knowledge and expertise.
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
What is the most important nursing intervention for patien ts who receive neuromuscular blocking agents?
Correct Answer: B
Rationale: The correct answer is B: Assess neurological status every 30 minutes. This intervention is crucial for patients receiving neuromuscular blocking agents to monitor for any adverse effects such as respiratory depression or paralysis. Regular assessments help ensure early detection of complications and prompt intervention. A: Administering sedatives in conjunction with neuromuscular blocking agents can potentiate respiratory depression and lead to respiratory compromise. C: Avoiding interaction with the patient is not appropriate as communication and patient interaction are important aspects of nursing care. D: Restraint should be avoided as it can increase the risk of complications such as pressure ulcers, anxiety, and decreased respiratory function. Overall, regular neurological assessments are essential for ensuring patient safety and prompt intervention in case of any complications.
Question 9 of 9
The removal of plasma water and some low–molecular weight particles by using a pressure or osmotic gradient is known as
Correct Answer: D
Rationale: Ultrafiltration is the correct answer because it involves the removal of plasma water and low-molecular weight particles by using a pressure or osmotic gradient. During ultrafiltration, the pressure gradient pushes the fluid through a semipermeable membrane, separating the substances based on their molecular size. This process allows for the selective removal of unwanted substances while retaining essential components. Dialysis (choice A) involves the removal of waste products from the blood, but it does not specifically target plasma water and low-molecular weight particles. Diffusion (choice B) is the passive movement of particles from an area of higher concentration to an area of lower concentration and is not specific to the removal of plasma water. Clearance (choice C) refers to the rate at which a substance is removed from the blood and does not involve the mechanism of pressure or osmotic gradient utilized in ultrafiltration.