ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 of 5
The nurse is caring for a patient who has a temporary percutaneous dialysis catheter in place. In caring for this patient, the nurse should
Correct Answer: C
Rationale: The correct answer is C because assessing the catheter site for redness and/or swelling is crucial for early detection of infection. Redness and swelling are common signs of infection at the catheter site, which requires prompt intervention. Applying a sterile gauze dressing (choice A) is not necessary for a temporary percutaneous dialysis catheter. Replacing the transparent dressing every 10 days (choice B) is not recommended as it can increase the risk of infection. Using the catheter for drawing blood samples (choice D) is not appropriate as it can introduce contaminants and increase the risk of infection. Regular assessment of the catheter site is essential for early detection and prevention of complications.
Question 2 of 5
Identify which substances in the glomerular filtrate would indicate a problem with renal function. (Select all that apply.)
Correct Answer: A
Rationale: The presence of protein in the glomerular filtrate indicates a problem with renal function because in healthy kidneys, proteins are retained in the blood and not filtered into the urine. If protein is found in the filtrate, it suggests damage to the glomerular filtration barrier. Sodium, creatinine, and red blood cells are normally present in the filtrate and are not indicative of renal dysfunction. Sodium is freely filtered and reabsorbed, creatinine is a waste product of muscle metabolism excreted by the kidneys, and a small number of red blood cells may be filtered due to their small size. Therefore, protein in the glomerular filtrate is the most specific indicator of renal dysfunction.
Question 3 of 5
A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma?
Correct Answer: D
Rationale: The correct answer is D, Metoprolol tartrate (Lopressor). Metoprolol is a cardioselective beta-blocker that primarily targets beta-1 receptors in the heart, making it less likely to exacerbate asthma compared to non-selective beta-blockers like Propranolol (choice B) and Pindolol (choice C). Carteolol (choice A) is also a non-selective beta-blocker and can potentially worsen asthma symptoms. Metoprolol's selectivity for beta-1 receptors minimizes bronchoconstriction, making it the safest choice for a client with asthma and high blood pressure.
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
During a client assessment, the client says, 'I can't walk very well.' Which action should the nurse implement first?
Correct Answer: D
Rationale: The correct answer is D: Identify the problem. This is the first action the nurse should take in the nursing process as it helps in understanding the client's issue. By identifying the problem, the nurse can gather more information through further assessment to determine the underlying cause of the client's difficulty in walking. This step is crucial for developing an effective care plan and interventions. A: Predict the likelihood of the outcome - This choice is not appropriate as predicting the outcome should come after identifying the problem and implementing interventions. B: Consider alternatives - While considering alternatives is important in the decision-making process, it is not the immediate action needed in this scenario. C: Choose the most successful approach - This choice is premature as the nurse needs to first identify the problem before determining the most successful approach.