ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 of 9
The nurse is caring for a patient who is orally intubated and on a mechanical ventilator. The nurse believes that the patient is experiencing excess anxiety. For this patient, what behavior best indicates anxiety?
Correct Answer: A
Rationale: The correct answer is A: Restlessness. Restlessness is a common behavioral indicator of anxiety in patients. In this scenario, a patient who is orally intubated and on a ventilator may not be able to verbally express anxiety, making restlessness a more prominent sign. Verbalization may not be possible due to intubation. While increased respiratory rate can be a symptom of anxiety, it is also a common physiological response in patients on mechanical ventilation. A Glasgow Coma Scale score of 3 indicates severe impairment of consciousness, not specifically anxiety.
Question 2 of 9
The nurse is caring for a patient who is orally intubated and on a mechanical ventilator. The nurse believes that the patient is experiencing excess anxiety. For this patient, what behavior best indicates anxiety?
Correct Answer: A
Rationale: The correct answer is A: Restlessness. Restlessness is a common behavioral indicator of anxiety in patients. In this scenario, a patient who is orally intubated and on a ventilator may not be able to verbally express anxiety, making restlessness a more prominent sign. Verbalization may not be possible due to intubation. While increased respiratory rate can be a symptom of anxiety, it is also a common physiological response in patients on mechanical ventilation. A Glasgow Coma Scale score of 3 indicates severe impairment of consciousness, not specifically anxiety.
Question 3 of 9
The son of a dying patient tells the nurse, 'Mother doesn’t respond anymore when I visit. I don’t think she knows that I am here.' Which response by the nurse is appropriate?
Correct Answer: B
Rationale: The correct answer is B because withdrawal is a common psychological response in the dying process. The nurse should explain to the son that his mother's lack of response may be her way of preparing to leave life. This response validates the son's concerns while providing reassurance. Choice A is incorrect because cutting back visits may not address the underlying issue of the mother's withdrawal. Choice C is incorrect because stimulating the mother may not be beneficial or appropriate in this situation. Choice D is incorrect because not all patients experience a lack of awareness at the end of life, and assuming so may not be helpful in this context.
Question 4 of 9
Ideally, by whom and when should an advance directive be developed?
Correct Answer: C
Rationale: Step-by-step rationale for choice C: 1. Advance directives should be made by the patient to reflect their wishes. 2. Developing it before illness ensures clarity and avoids confusion. 3. Patients may not be able to make informed decisions in critical conditions. 4. Family or surrogates may not accurately represent the patient's wishes. Summary: A - Family in critical condition may not know the patient's wishes. B - Hospital admission process may be too late for clear decision-making. D - Healthcare surrogate may not fully understand the patient's preferences.
Question 5 of 9
Which is the most important outcome for a patient receiving palliative care?
Correct Answer: B
Rationale: The correct answer is B: Improvement in symptoms and quality of life. In palliative care, the primary focus is on enhancing the patient's quality of life by managing symptoms and providing comfort. This is achieved through effective symptom control, psychosocial support, and improving overall well-being. Complete resolution of the underlying disease (A) is often not possible in palliative care as the focus shifts from curative treatments to comfort care. Increased adherence to curative treatments (C) may not be the main goal in palliative care, as the emphasis is on improving the patient's comfort rather than prolonging life. Achievement of long-term survival goals (D) is not typically the primary outcome in palliative care, as the focus is on providing support and care for patients with life-limiting illnesses.
Question 6 of 9
Gastric lavage and administration of activated charcoal are ordered for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which action should the nurse plan to do first?
Correct Answer: B
Rationale: The correct answer is B: Assist with the intubation of the patient. In this scenario, the patient is unconscious and has ingested a potentially harmful substance. Intubation is the first priority to maintain the patient's airway and ensure adequate oxygenation. This step is crucial in preventing aspiration of gastric contents and securing the patient's respiratory status. Inserting a large-bore orogastric tube (choice A) is not the priority as airway management takes precedence. Preparing a syringe with saline (choice C) is unnecessary at this stage. Giving the first dose of activated charcoal (choice D) should only be done after securing the airway to prevent aspiration.
Question 7 of 9
A normal glomerular filtration rate is
Correct Answer: B
Rationale: The correct answer is B (80 to 125 mL/min) because this range reflects the normal glomerular filtration rate (GFR) in adults. GFR measures the rate at which blood is filtered by the kidneys, typically around 125 mL/min. A GFR below 60 mL/min indicates kidney dysfunction, making option A incorrect. Option C (125 to 180 mL/min) is above the normal range. Option D (more than 189 mL/min) is too high and could indicate hyperfiltration, common in conditions like diabetes. Therefore, choice B is the most appropriate within the normal GFR range.
Question 8 of 9
The charge nurse has a Vigileo pulse contour cardiac output monitoring system available for use in the surgical intensive care unit. For which patient isa buisrbe.c oomf /ttehsits device most appropriate?
Correct Answer: B
Rationale: The correct answer is B because a mechanically ventilated patient with cardiogenic shock being treated with an intra-aortic balloon pump would benefit most from having a Vigileo pulse contour cardiac output monitoring system. This device provides continuous cardiac output monitoring and can help guide hemodynamic management in critically ill patients, especially those with hemodynamic instability like cardiogenic shock. It allows for real-time adjustments of fluid and vasoactive medications to optimize cardiac output and tissue perfusion. Choice A is incorrect because a patient with a history of aortic insufficiency and postoperative myocardial infarction may not require continuous cardiac output monitoring like the patient in choice B. Choice C is incorrect as the patient with atrial fibrillation and paroxysmal supraventricular tachycardia does not necessarily need cardiac output monitoring. Choice D is also incorrect as a mechanically ventilated patient following repair of an acute bowel obstruction may not require continuous cardiac output monitoring unless there are specific complications.
Question 9 of 9
Upon entering the room of a patient with a right radial arte rial line, the nurse assesses the waveform to be slightly dampened and notices blood to bea bbirabc.ckoemd/te ustp into the pressure tubing. What is the best action by the nurse?
Correct Answer: B
Rationale: The correct answer is B: Disconnect the flush system from the arterial line catheter. This action is necessary to prevent air from entering the patient's bloodstream, which can lead to air embolism. By disconnecting the flush system, the nurse stops the flow of air and ensures patient safety. Checking the inflation volume of the pressurized bag (A) is not the immediate concern in this situation. Zero referencing the transducer system (C) is unrelated to the issue of air entering the arterial line. Reducing the number of stopcocks in the flush system tubing (D) does not address the immediate risk of air embolism.