ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 of 5
The nurse is caring for a mechanically ventilated patient following bilateral lung transplantation. When planning the care of this patient, what is the priority nursing intervention?
Correct Answer: A
Rationale: The correct answer is A: Thirty-degree elevation of the head of the bed. This is the priority nursing intervention for a mechanically ventilated patient following bilateral lung transplantation because it helps optimize ventilation-perfusion matching, reduces the risk of aspiration, and improves oxygenation. Elevating the head of the bed also decreases the risk of ventilator-associated pneumonia. B: Endotracheal suctioning as needed is important but not the priority intervention in this case. C: Frequent side to side repositioning is important for preventing pressure ulcers but is not the priority for a ventilated patient post-lung transplant. D: Sequential compression stockings are used for preventing deep vein thrombosis, which is important but not the priority in this scenario.
Question 2 of 5
The nurse is assisting with endotracheal intubation of the p atient and recognizes that the procedure will be done in what order? (Put a comma and s pace between each answer choice.)
Correct Answer: D
Rationale: The correct answer is D. The first step in endotracheal intubation is to insert the endotracheal tube with a laryngoscope and blade to visualize the vocal cords and guide the tube into the trachea. This ensures proper placement of the tube for effective ventilation. Assessing the balloon symmetry (Choice A) and lung fields (Choice B) would come after the tube is successfully inserted. Inflating the balloon of the endotracheal tube (Choice C) should be the last step to secure the tube in place.
Question 3 of 5
The nurse uses the Situation-Background-Assessment-Recommendation (SBAR) format to communicate a change in patient status to a healthcare provider. In which order should the nurse make the following statements?
Correct Answer: B
Rationale: Step 1: Start with Background - statement B provides relevant background information about the patient's current condition and why there is a need for communication. Step 2: Move on to Situation - statement D sets the current situation where the nurse expresses concern about the patient's symptom. Step 3: Next is Assessment - statement C details the nurse's assessment findings, highlighting the critical aspects of the patient's condition. Step 4: End with Recommendation - statement A suggests the necessary action to be taken based on the assessment findings. This order ensures a clear and structured communication process. Summary: - Choice A is incorrect as the recommendation should come after providing background, situation, and assessment. - Choice C is incorrect as assessment details should precede the patient's critical condition. - Choice D is incorrect as the situation should be explained before expressing concern.
Question 4 of 5
A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain. Which organ function is most important for the nurse to monitor?
Correct Answer: B
Rationale: The correct answer is B: Liver. The nurse should monitor liver function in this client because acetaminophen is primarily metabolized in the liver. Alcohol abuse can also contribute to liver damage, increasing the risk of liver toxicity from acetaminophen. Monitoring liver function tests like AST, ALT, and bilirubin levels can help detect any liver damage early. Choice A, cardiorespiratory, is not directly related to acetaminophen or alcohol abuse in this scenario. Choice C, sensory, is not relevant to monitoring organ function in this context. Choice D, kidney, is not the primary concern because acetaminophen is mainly metabolized in the liver, and kidney function is not typically affected by acetaminophen use.
Question 5 of 5
Warning signs that can assist the critical care nurse in reco gnizing that an ethical dilemma may exist include which of the following? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A because when family members are confused about the patient's condition or treatment, it can indicate a lack of communication or understanding, leading to a potential ethical dilemma. This confusion may result in conflicting views on what is best for the patient, potentially leading to disagreements and ethical conflicts. Choice B is incorrect because although family conflict can lead to ethical dilemmas, it is not a direct warning sign that an ethical dilemma exists. Choice C is incorrect because the family asking not to inform the patient about treatment is more related to communication preferences rather than a clear indication of an ethical dilemma. Choice D is incorrect because a deteriorating patient condition, while concerning, does not directly signal an ethical dilemma unless there are specific ethical considerations involved in the treatment decisions.