ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 of 5
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 5
When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87°F (30.6°C), which assessment indicates that the nurse should discontinue active rewarming?
Correct Answer: D
Rationale: The correct answer is D. When rewarming a hypothermic patient, the goal is to gradually increase their core temperature. A core temperature of 94°F (34.4°C) is still below the normal range, but it indicates that the rewarming process is working. Shivering (A) is a normal response to rewarming. A decrease in blood pressure (B) may be expected due to peripheral vasodilation during rewarming. Developing atrial fibrillation (C) may be a concern but does not necessarily indicate that rewarming should be discontinued. Therefore, choice D is correct as it signifies progress in the rewarming process.
Question 3 of 5
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 4 of 5
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 5 of 5
A 75-year-old patient, who suffered a massive stroke 3 weeks ago, has been unresponsive and
Correct Answer: E
Rationale: Step 1: The scenario describes a decision made based on the patient's previously expressed wishes. Step 2: The decision aligns with the principle of respecting patient autonomy. Step 3: The term that best describes this situation is "Advance Directive." Summary: - A: Incorrect, as it involves actively ending the patient's life without their consent. - B: Incorrect, as euthanasia involves intentionally causing death to relieve suffering. - C: Incorrect, as palliative care focuses on improving quality of life for the patient. - D: Incorrect, as withdrawal of life support involves discontinuing medical interventions, not honoring the patient's wishes.
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