ATI RN
Critical Care Nursing Questions Questions
Question 1 of 9
The nurse is caring for a critically ill patient with a very concerned family. Given that the family is under high stress, what nursing intervention will best ameliorate their stress while preserving independence?
Correct Answer: A
Rationale: The correct answer is A: Encourage the family to participate in patient care tasks. This intervention helps to alleviate stress by involving the family in care, promoting a sense of control and empowerment. It also fosters a collaborative relationship between the family and healthcare team. The other choices are incorrect because B only focuses on asking questions but doesn't actively involve the family in care. C may add pressure on the selected representative and exclude others. D limits family involvement and may increase stress by restricting visitation.
Question 2 of 9
Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide?
Correct Answer: A
Rationale: The correct answer is A because breastfeeding helps stimulate the uterus to contract, which reduces the risk of postpartum hemorrhage in the mother. When the baby suckles at the breast, it triggers the release of oxytocin, a hormone that causes the uterus to contract. This contraction helps the uterus to return to its pre-pregnancy size and shape, promoting faster healing and reducing bleeding. Choice B is incorrect because lactation initiation is a separate process that involves hormonal changes and milk production, which may not occur immediately after delivery. Choice C is incorrect as bonding can occur through various interactions beyond breastfeeding. Choice D is incorrect as neonatal hypoglycemia is primarily prevented by ensuring the baby receives adequate nutrition, which can also be achieved through other feeding methods besides breastfeeding.
Question 3 of 9
The nurse cares for a patient with lung cancer in a home hospice program. Which action by the nurse is most appropriate?
Correct Answer: B
Rationale: The correct answer is B because in a home hospice program, it is essential for the nurse to provide holistic care that includes addressing the patient's emotional and psychological needs. Encouraging the patient to discuss past life events and their meaning can help them process emotions, find closure, and improve their quality of life. This approach aligns with the principles of palliative care, which focus on enhancing comfort and well-being. Choice A is incorrect because discussing cancer risk factors and lifestyle modifications may not be relevant or beneficial for a patient in a hospice program. Choice C is incorrect because chemotherapy and radiation are typically not part of hospice care, which focuses on comfort rather than curative treatments. Choice D is incorrect because a thorough head-to-toe assessment multiple times a week may not be necessary or appropriate for a patient in a hospice program.
Question 4 of 9
An elderly patient is admitted to the ICU with stage IV lung cancer, diabetes mellitus, and congestive heart failure. The health care team assembled to care for her is large and diverse, including an oncologist, a pulmonologist, an endocrinologist, a cardiologist, and others. The patient is not expected to survive more than a few weeks, and her husband is overwhelmed with stress and grief. Which nurse competency or competencies are most needed in this situation? Select all that apply.
Correct Answer: B
Rationale: The correct answer is B: Caring practices. In this situation, the patient and her husband are dealing with complex medical conditions and emotional distress. Caring practices involve providing compassionate, empathetic, and supportive care to the patient and her family members during this difficult time. The nurse needs to show sensitivity, understanding, and emotional support to help them cope with their situation. Clinical judgment (A) is important but not the primary focus in this scenario. Collaboration (C) is essential in the interdisciplinary team, but caring practices take precedence in addressing the emotional needs. Response to diversity (D) is also important, but in this case, the focus is more on providing compassionate care rather than addressing cultural or social diversity issues.
Question 5 of 9
To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should:
Correct Answer: D
Rationale: The correct answer is D because inflating the cuff until a slight leak is heard only at peak inflation ensures it is adequately sealed but not overinflated, preventing complications like tracheal injury or pressure necrosis. Choice A lacks specificity and can lead to overinflation. Choice B may result in overinflation as the firmness of the balloon is subjective. Choice C relies on a specific pressure reading, which may vary based on factors like tube size and patient anatomy, potentially leading to under- or overinflation.
Question 6 of 9
A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, 'I had a temperature of 103.9°F (39.9°C) at home.' The nurse’s first action should be to:
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's current vital signs. The nurse's first action should be to gather objective data to assess the patient's condition and determine the urgency of the situation. Vital signs, including temperature, heart rate, blood pressure, and respiratory rate, provide crucial information for the initial assessment. This will help the nurse identify any signs of sepsis, shock, or other serious conditions that require immediate intervention. The other choices are incorrect because: B: Giving acetaminophen without assessing the patient's vital signs and determining the cause of the symptoms could mask important clinical information and delay appropriate treatment. C: While obtaining a urine sample may be necessary later to rule out a urinary tract infection, it is not the most immediate priority in this case. D: Delaying the patient's assessment and care based on estimated wait times is not appropriate when the patient presents with potentially serious symptoms. Immediate evaluation is required in this scenario.
Question 7 of 9
A patient presents to the emergency department in acute re spiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation?
Correct Answer: B
Rationale: The correct answer is B: Mechanical ventilation via an endotracheal tube. In acute respiratory failure, especially in the setting of pneumonia and COPD, mechanical ventilation is often necessary to support breathing. Endotracheal intubation allows for precise control of airway patency, oxygenation, and ventilation. Emergency tracheostomy (choice A) is typically reserved for long-term ventilatory support. Noninvasive positive-pressure ventilation (choice C) may not provide sufficient support in severe cases. Oxygen via bag-valve-mask (choice D) may not be adequate for ventilatory support in acute respiratory failure.
Question 8 of 9
Positive end-expiratory pressure (PEEP) is a mode of ventaiblairbto.croym /atessst istance that produces which of the following conditions
Correct Answer: D
Rationale: The correct answer is D because positive end-expiratory pressure (PEEP) is a mode of ventilation where pressure is maintained in the lungs at the end of expiration. This helps prevent alveolar collapse and improves oxygenation. Option A is incorrect because PEEP does not deliver a full preset tidal volume with each breath initiation. Option B is incorrect because tidal volume in PEEP is not solely determined by the patient's ability to generate negative pressure. Option C is incorrect because in PEEP, breaths are delivered irrespective of the patient's respiratory drive.
Question 9 of 9
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next?
Correct Answer: B
Rationale: Rationale: The correct action is to observe the patient's respiratory effort next. This step ensures that the patient's breathing remains stable and adequate. If respiratory effort is compromised, immediate intervention is required. Checking for bilateral pulses (A) is important but comes after ensuring respiratory status. Checking level of consciousness (C) is also crucial but not as immediate as monitoring breathing. Examining for external bleeding (D) is important but not the priority when airway and breathing are already determined to be clear.