ATI RN
Critical Care Nursing Questions and Answers PDF Questions
Question 1 of 5
The nurse is caring for a patient admitted with a traumatic brain injury following a motor vehicle crash. The patient’s Glasgow Coma Score is 3 anda binirbte.cromm/ittetset ntly withdraws when painful stimuli are introduced. The patient is ventilator dependent and occasionally takes a spontaneous breath. The primary care provider explains to the family that the patient has severe neurological impairment and it is not expected that the patient will ever recover consciousness. What concept does this situation depict?
Correct Answer: C
Rationale: The correct answer is C: A persistent vegetative state. This choice is correct because the patient exhibits minimal responsiveness, only withdrawing to painful stimuli, and lacks meaningful interaction or consciousness. A persistent vegetative state is characterized by preserved wakefulness without awareness, which aligns with the patient's condition. Choice A: An organ donor is incorrect because the patient's neurological impairment does not necessarily indicate readiness for organ donation. Choice B: Brain death is incorrect because the patient still exhibits some reflexive responses, indicating a level of brain function beyond brain death. Choice D: Terminally ill is incorrect as it does not specifically address the patient's neurological status and prognosis, which is better described by a persistent vegetative state.
Question 2 of 5
Which statement made by a staff nurse identifying guidelianbeirsb .fcoomr /pteaslt liative care would need corrected?
Correct Answer: C
Rationale: The correct answer is C because palliative care is not just for the dying but also for those with serious illnesses. A: Correct - basic nursing care is essential in palliative care. B: Correct - common symptoms in palliative care include nausea, agitation, and sleep disturbance. D: Correct - palliative care aims to relieve symptoms and improve quality of life. Choice C is incorrect as it wrongly implies palliative care is only for the dying, which is a misconception.
Question 3 of 5
The nurse notes that a patient’s endotracheal tube (ET), which was at the 22 cm mark, is now at the 25 cm mark and the patient is anxious and restless. Which action should the nurse take next?
Correct Answer: C
Rationale: The correct answer is C: Listen to the patient’s breath sounds. Moving from 22 cm to 25 cm may indicate ET tube migration. Checking breath sounds can confirm proper tube placement. A may not address the underlying issue. B could worsen the situation if the tube is misplaced. D is not urgent compared to assessing airway integrity.
Question 4 of 5
Palliation care includes what goals? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A (Pain relief) because palliative care aims to provide comfort and improve the quality of life for individuals with serious illnesses. Pain relief is a crucial goal in palliative care to alleviate physical suffering. Nausea relief (B) is also commonly addressed in palliative care, but it is not a universal goal. Psychological support (C) is an important aspect of palliative care but is not always a primary goal. Withdrawal of life-support interventions (D) is not a goal of palliative care, as palliative care focuses on symptom management and improving quality of life, not hastening death.
Question 5 of 5
The emergency department (ED) nurse is initiating therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)?
Correct Answer: D
Rationale: Correct Answer: D - Give acetaminophen (Tylenol) 650 mg per nasogastric tube. Rationale: LPNs/LVNs are trained to administer medications, including oral and nasogastric routes. Giving acetaminophen via nasogastric tube is within their scope of practice. LPNs/LVNs should have the knowledge and skills to safely administer this medication as part of the hypothermia protocol. Summary of other choices: A: Continuously monitor heart rhythm - This requires specialized training and skills typically within the scope of registered nurses or cardiac monitoring technicians. B: Check neurologic status every 2 hours - Assessing neurologic status requires critical thinking and clinical judgment, which are typically responsibilities of registered nurses. C: Place cooling blankets above and below the patient - Positioning and managing cooling devices may require specific training and should be done under the supervision of a registered nurse.