ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 of 9
The nurse is caring for a critically ill patient with terminal cancer. The monitor alarms and shows ventricular tachycardia. The patient does not have a “do not resuscitate” order written on the chart. What is the appropriate nursing action?
Correct Answer: D
Rationale: The correct answer is D: Initiate CPR and call a code. In this scenario, the patient is critically ill with ventricular tachycardia, a life-threatening arrhythmia. Since there is no "do not resuscitate" order, the appropriate nursing action is to initiate CPR immediately to attempt to restore the patient's cardiac function and circulation. Calling a code will ensure that a team of healthcare providers can respond promptly with necessary interventions. Options A and B involve unnecessary delays in potentially life-saving interventions. Option C is incorrect as withholding intubation can compromise the patient's airway and oxygenation. Thus, option D is the most appropriate action to prioritize the patient's safety and well-being in this critical situation.
Question 2 of 9
A patient is admitted to the hospital with multiple trauma aabnirdb .ceoxmte/tensst ive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vas cular resistance of 3000 dynes/sec/cm5, and a hematocrit of 20%. The nurse anticip ates administration of which the following therapies or medications?
Correct Answer: C
Rationale: The correct answer is C: Dobutamine infusion. In this scenario, the patient is experiencing hypovolemic shock due to significant blood loss, resulting in low blood pressure, tachycardia, and low cardiac output. Dobutamine is a positive inotropic agent that increases cardiac contractility and output, helping to improve tissue perfusion. Blood transfusion (A) is a common intervention for hypovolemic shock, but in this case, the patient's hematocrit is low, indicating dilutional anemia rather than acute blood loss, so addressing the cardiac output is more urgent. Furosemide (B) is a diuretic that would exacerbate the hypovolemia and worsen the patient's condition. Dopamine (D) is a vasopressor that primarily increases blood pressure, but in this case, the patient's low cardiac output is the main concern, making dobutamine a more appropriate choice.
Question 3 of 9
The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a patient who is mechanically ventilated. Ensuring that the aaibri-rbf.lcuoimd/ teinstt erface is at the level of the phlebostatic axis, what is the best nursing action?
Correct Answer: C
Rationale: The correct answer is C because placing the patient with the head of the bed elevated 30 degrees is the best position for obtaining an accurate PAOP reading. Elevating the head of the bed helps to align the phlebostatic axis with the atrium, ensuring an accurate measurement of PAOP. This position reduces the impact of hydrostatic pressure on the reading. Options A and D are incorrect because the supine position and recording during exhalation or just before the increase in pressures during inhalation can lead to inaccurate readings. Option B is incorrect because documenting the average PAOP after three measurements does not address the importance of positioning for accuracy.
Question 4 of 9
Family assessment is essential in order to meet family nee ds. Which of the following must be assessed first to assist the nurse in providing family-centered care?
Correct Answer: A
Rationale: The correct answer is A because assessing the patient and family's developmental stages and needs is crucial in understanding their current situation and determining the appropriate care plan. By assessing developmental stages, the nurse can tailor interventions to meet the family's specific needs. This assessment also helps in identifying potential challenges or areas requiring support. Choice B is incorrect as it focuses solely on the physical environment and does not address the family's developmental stages and needs. Choice C is incorrect as it emphasizes identifying family members without considering the importance of understanding their developmental stages and needs in providing family-centered care. Choice D is incorrect as it concentrates on family dynamics without directly addressing the crucial aspect of assessing developmental stages and needs for effective family-centered care.
Question 5 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 6 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 7 of 9
The charge nurse has a Vigileo pulse contour cardiac output monitoring system available for use in the surgical intensive care unit. For which patient isa buisrbe.c oomf /ttehsits device most appropriate?
Correct Answer: B
Rationale: The correct answer is B because a mechanically ventilated patient with cardiogenic shock being treated with an intra-aortic balloon pump would benefit most from having a Vigileo pulse contour cardiac output monitoring system. This device provides continuous cardiac output monitoring and can help guide hemodynamic management in critically ill patients, especially those with hemodynamic instability like cardiogenic shock. It allows for real-time adjustments of fluid and vasoactive medications to optimize cardiac output and tissue perfusion. Choice A is incorrect because a patient with a history of aortic insufficiency and postoperative myocardial infarction may not require continuous cardiac output monitoring like the patient in choice B. Choice C is incorrect as the patient with atrial fibrillation and paroxysmal supraventricular tachycardia does not necessarily need cardiac output monitoring. Choice D is also incorrect as a mechanically ventilated patient following repair of an acute bowel obstruction may not require continuous cardiac output monitoring unless there are specific complications.
Question 8 of 9
The nurse is caring for a terminally ill patient who has chosen palliative care. Which goal should the nurse prioritize when planning care?
Correct Answer: B
Rationale: The correct answer is B: Manage the patient's pain and symptoms. In palliative care, the primary goal is to provide comfort and improve quality of life for terminally ill patients. Managing pain and symptoms is crucial in achieving this goal. By addressing pain and symptoms, the nurse can help enhance the patient's comfort and well-being. Other choices are incorrect because palliative care focuses on improving quality of life rather than curing the underlying disease (A), prolonging life expectancy (C), or primarily addressing family concerns (D). Prioritizing pain and symptom management aligns with the holistic approach of palliative care.
Question 9 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.