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 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 3 of 5
The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the patient’s urine output has been less than 20 mL/hour for the past 2 hours. The patient’s blood pressure is 100/60 mm Hg, and the pulse is 110 beats/min. Previously, the pulse was 90 beats/min with a blood pressure of 120/80 mm Hg. The nurse should
Correct Answer: A
Rationale: The correct answer is A: contact the provider and expect a prescription for a normal saline bolus. The patient is showing signs of hypovolemia with decreased urine output, low blood pressure, and elevated heart rate. This indicates inadequate perfusion and potential hypovolemic shock. Administering a normal saline bolus will help restore intravascular volume and improve perfusion. Waiting for the provider to make rounds (option B) could delay necessary intervention. Continuing to evaluate urine output for 2 more hours (option C) is not appropriate given the patient's current condition. Ignoring the urine output (option D) is dangerous as it could lead to further complications.
Question 4 of 5
A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should:
Correct Answer: B
Rationale: The correct answer is B: Obtain a Glasgow Coma Scale score. During the primary survey, assessing the patient's level of consciousness is crucial as it helps determine the severity of the injury and guides further management. The Glasgow Coma Scale is a standardized tool used to assess the level of consciousness based on eye opening, verbal response, and motor response. It provides valuable information about the patient's neurological status. A: Obtaining a complete set of vital signs is important but assessing the level of consciousness takes priority in this scenario. C: Asking about chronic medical conditions is important but not as critical as assessing the patient's level of consciousness during the primary survey. D: Attaching a cardiac electrocardiogram monitor is not necessary during the primary survey unless there are specific indications of cardiac issues, which are not evident in this case. In summary, obtaining a Glasgow Coma Scale score is essential for assessing the patient's level of consciousness and determining the severity of the injury during the primary survey.
Question 5 of 5
A patient is transferred to the ICU from the Birth Center of the hospital in the middle of the night after experiencing complications during delivery of her baby. The patients husband is anxious and explains to the ICU nurse that he doesnt understand why his wife has been moved to the ICU. She is going to die, isnt she? he asks the nurse. What is the nurses best response?
Correct Answer: A
Rationale: The correct answer is A because it addresses the husband's concern directly by assuring him that every measure will be taken to provide the best care for his wife. This response shows empathy and provides reassurance, which is crucial in such a stressful situation. It helps to alleviate the husband's anxiety and fear by emphasizing the hospital's commitment to his wife's well-being. Explanation for why the other choices are incorrect: B: This response does not address the husband's immediate concern about his wife's well-being and may come across as dismissive. C: Offering a place to relax does not address the husband's specific question and does not provide the information he is seeking. D: Discussing health insurance is not appropriate at this moment of crisis and does not address the husband's fears about his wife's condition.
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