ATI RN
Critical Care Nursing Exam Questions Questions
Question 1 of 5
The nurse is caring for a patient receiving continuous norepinephrine (Levophed) IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted?
Correct Answer: B
Rationale: The correct answer is B because a low Mean Arterial Pressure (MAP) indicates inadequate perfusion, which may require adjusting the norepinephrine infusion rate to increase blood pressure. A: A heart rate of 58 beats/minute is within a normal range and may not necessarily indicate a need for adjustment. C: Elevated Systemic Vascular Resistance (SVR) may be an expected response to norepinephrine and does not necessarily indicate a need for adjustment. D: A low Pulmonary Artery Wedge Pressure (PAWP) may indicate fluid volume deficit but does not directly relate to the need for adjusting norepinephrine infusion rate.
Question 2 of 5
A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most important to discuss with the health care provider before starting the SBT?
Correct Answer: A
Rationale: The correct answer is A: New ST segment elevation is noted on the cardiac monitor. This finding is concerning because it may indicate myocardial ischemia or infarction, which can be exacerbated by the physiological stress of weaning from mechanical ventilation. It is crucial to address any cardiac issues before initiating a spontaneous breathing trial to prevent potential cardiac complications during the weaning process. Explanation for why the other choices are incorrect: B: Enteral feedings being given through an orogastric tube are not contraindicated for starting a spontaneous breathing trial. C: Scattered rhonchi heard when auscultating breath sounds may indicate retained secretions but are not a contraindication for a spontaneous breathing trial. D: The use of HYDROmorphone to treat postoperative pain is not a contraindication for a spontaneous breathing trial unless it is causing respiratory depression, which would need to be addressed separately.
Question 3 of 5
During the primary survey of a patient with severe leg trauma, the nurse observes that the patient’s left pedal pulse is absent and the leg is swollen. Which action will the nurse take next?
Correct Answer: B
Rationale: The correct answer is B: Assess further for a cause of the decreased circulation. The nurse should prioritize assessing the cause of the absent left pedal pulse and leg swelling to address the severe leg trauma effectively. This step involves identifying potential vascular compromise or compartment syndrome, which are critical conditions requiring immediate intervention. Sending blood for a complete blood count (A) is not the priority in this situation. Finishing the primary survey (C) may delay addressing the circulation issue. Starting normal saline infusion (D) without addressing the circulation problem first could potentially worsen the condition. Therefore, assessing further for the cause of decreased circulation is the most appropriate next step to ensure timely and appropriate management of the patient's condition.
Question 4 of 5
A 22-year-old patient who experienced a near-drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?
Correct Answer: C
Rationale: The correct answer is C: Auscultate breath sounds. After a near-drowning incident, the main concern is potential respiratory complications such as aspiration pneumonia or pulmonary edema. Auscultating breath sounds will help the nurse assess for any signs of respiratory distress or complications. This assessment is crucial for early detection and intervention. A: Auscultating heart sounds is important but not as crucial as assessing breath sounds in this scenario. B: Palpating peripheral pulses is important for circulation assessment but does not address the immediate concern of respiratory complications. D: Checking pupil reaction to light is more relevant for neurological assessment and not as critical as assessing breathing in this situation.
Question 5 of 5
The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment?
Correct Answer: D
Rationale: The correct answer is D: A patient with paradoxical chest movements. This indicates flail chest, a life-threatening condition where a segment of the chest wall moves independently from the rest. 1. Flail chest can lead to respiratory compromise and potential respiratory failure. 2. Immediate intervention is needed to stabilize the chest wall and support breathing. 3. Without prompt treatment, the patient can develop hypoxia and potentially progress to cardiac arrest. Summary: - Choice A: No pedal pulses may indicate vascular compromise but does not pose an immediate threat to life. - Choice B: Open femur fracture requires urgent treatment but does not have the same immediate life-threatening implications as flail chest. - Choice C: Bleeding facial lacerations can be managed after addressing more critical injuries like flail chest.