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
A nurse in the ICU is responding to a patient who has just gone into cardiac arrest. A moment later, the nurse is notified that another patient has just gone into anaphylactic shock due to a drug allergy. She is conflicted as to what to do, as she is the only nurse available at the moment to tend to both patients. Which component of a healthy work environment is lacking in this scenario?
Correct Answer: B
Rationale: The correct answer is B: Appropriate staffing. In this scenario, the nurse is conflicted because she is the only nurse available to tend to both critical patients. Appropriate staffing ensures that there are enough healthcare professionals to provide timely and effective care to patients in need. In this situation, the lack of adequate staffing is evident as the nurse is overwhelmed and unable to give proper attention to both patients simultaneously. Effective decision making (choice A) can be hindered by inadequate staffing but is not the primary issue here. Authentic leadership (choice C) and meaningful recognition (choice D) are important components of a healthy work environment but are not directly related to the lack of staffing in this scenario.
Question 3 of 9
As part of the admission process, the nurse asks several questions about family relationships. The nurse bases these actions on which rationale?
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct: 1. Involving the family in patient care is crucial for holistic care. 2. Assessing family relationships helps identify support systems and potential conflicts. 3. Understanding family dynamics aids in creating a comprehensive care plan. 4. Family involvement can enhance patient outcomes and satisfaction. Summary of incorrect choices: B. Irrelevant, as the focus is on patient-centered care, not just fulfilling an assessment tool. C. Personal curiosity is not a valid reason for assessing family relationships in healthcare. D. Conducting research on family patterns does not directly impact the immediate care of the patient.
Question 4 of 9
A patient is admitted to the hospital with multiple trauma aabnirdb .ceoxmte/tensst ive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vas cular resistance of 3000 dynes/sec/cm5, and a hematocrit of 20%. The nurse anticip ates administration of which the following therapies or medications?
Correct Answer: C
Rationale: The correct answer is C: Dobutamine infusion. In this scenario, the patient is experiencing hypovolemic shock due to significant blood loss, resulting in low blood pressure, tachycardia, and low cardiac output. Dobutamine is a positive inotropic agent that increases cardiac contractility and output, helping to improve tissue perfusion. Blood transfusion (A) is a common intervention for hypovolemic shock, but in this case, the patient's hematocrit is low, indicating dilutional anemia rather than acute blood loss, so addressing the cardiac output is more urgent. Furosemide (B) is a diuretic that would exacerbate the hypovolemia and worsen the patient's condition. Dopamine (D) is a vasopressor that primarily increases blood pressure, but in this case, the patient's low cardiac output is the main concern, making dobutamine a more appropriate choice.
Question 5 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 6 of 9
What are the diagnostic criteria for acute respiratory distress syndrome (ARDS)? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Bilateral infiltrates on chest x-ray study. ARDS diagnosis requires bilateral infiltrates on chest x-ray, indicative of non-cardiogenic pulmonary edema. Choice B, decreased cardiac output, is not a diagnostic criterion for ARDS. Choice C, PaO2/FiO2 ratio of less than 200, is a key diagnostic criteria for ARDS, indicating severe hypoxemia. Choice D, PAOP of more than 18 mm Hg, is used to differentiate between cardiogenic and non-cardiogenic causes of pulmonary edema, but it is not a direct diagnostic criterion for ARDS.
Question 7 of 9
The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will be most effective in addressing this problem?
Correct Answer: D
Rationale: The correct answer is D: Instill 5 mL of sterile saline into the ET before suctioning. This intervention helps to loosen and mobilize the thick secretions, making them easier to remove during suctioning. It is important to moisten the secretions to prevent mucosal damage and trauma during suctioning. A: Increasing suctioning frequency can lead to mucosal damage and increased risk of infection. B: Repositioning helps with ventilation and preventing pressure injuries, but it does not directly address the thick secretions. C: Adding water to enteral feedings will not directly address the thick secretions in the ET. In summary, instilling sterile saline into the ET before suctioning is the most effective intervention as it helps to loosen and mobilize thick secretions, making suctioning more effective and reducing the risk of mucosal damage.
Question 8 of 9
Family assessment is essential in order to meet family nee ds. Which of the following must be assessed first to assist the nurse in providing family-centered care?
Correct Answer: A
Rationale: The correct answer is A because assessing the patient and family's developmental stages and needs is crucial in understanding their current situation and determining the appropriate care plan. By assessing developmental stages, the nurse can tailor interventions to meet the family's specific needs. This assessment also helps in identifying potential challenges or areas requiring support. Choice B is incorrect as it focuses solely on the physical environment and does not address the family's developmental stages and needs. Choice C is incorrect as it emphasizes identifying family members without considering the importance of understanding their developmental stages and needs in providing family-centered care. Choice D is incorrect as it concentrates on family dynamics without directly addressing the crucial aspect of assessing developmental stages and needs for effective family-centered care.
Question 9 of 9
Which statement is true regarding the effects of caring for dying patients on nurses?
Correct Answer: D
Rationale: The correct answer, D, is supported by the fact that providing aggressive care to patients when nurses believe it is futile can lead to personal ethical conflicts and burnout. This is because nurses may experience moral distress when their values conflict with the care they are providing. This can result in emotional exhaustion and decreased job satisfaction, ultimately leading to burnout. Choice A is incorrect because attending funerals can be a way for nurses to process their grief and find closure, rather than creating additional stress. Choice B is incorrect because caring for dying patients can have emotional impacts on nurses, regardless of their professional approach. Choice C is incorrect because balancing care needs with personal emotional needs can be challenging and may not always be achievable.