ATI RN
Critical Care Nursing Questions and Answers PDF Questions
Question 1 of 9
The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 12 5 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO ) of 90% on a 50% venturi mask. 2 Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pres sure (PAOP) of 3 mm Hg. The nurse questions which of the following primary health care provider’s order?
Correct Answer: D
Rationale: The correct answer is D: Administer furosemide 20 mg intravenously. In this scenario, the patient is hypotensive with a low cardiac output, low CVP, and low PAOP, indicating cardiogenic shock. Administering furosemide, a diuretic, can worsen the patient's condition by further decreasing preload. This can lead to a decrease in cardiac output and exacerbate the shock state. The other options are more appropriate: A: Titrate supplemental oxygen to achieve a SpO > 94% - Correct, as improving oxygenation is essential in cardiogenic shock. B: Infuse 500 mL 0.9% normal saline over 1 hour - Correct, as fluid resuscitation may be necessary to improve perfusion. C: Obtain arterial blood gas and serum electrolytes - Correct, as these tests provide valuable information about the patient's oxygenation and electrolyte balance.
Question 2 of 9
Sleep often is disrupted for critically ill patients. Which nu rsing intervention is most appropriate to promote sleep and rest?
Correct Answer: A
Rationale: The correct answer is A: Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between intervals. This is the most appropriate intervention as medication timings can significantly impact sleep patterns of critically ill patients. Adjusting medication times can help synchronize rest periods, promoting uninterrupted sleep. Choice B is incorrect as encouraging constant conversation can disrupt sleep. Choice C is incorrect as the television noise can be stimulating and hinder rest. Choice D is incorrect as leaving the lights on can disrupt the patient's circadian rhythm and negatively impact sleep quality.
Question 3 of 9
When fluid is present in the alveoli what is the result?
Correct Answer: A
Rationale: The correct answer is A: Alveoli collapse and atelectasis occurs. When fluid is present in the alveoli, it impairs the surface tension necessary for the alveoli to remain open, leading to collapse and atelectasis. This prevents proper gas exchange, resulting in hypoxemia. Choice B is incorrect because impaired gas diffusion typically occurs with conditions affecting the alveolar-capillary membrane, not fluid in the alveoli. Choice C is incorrect as hypoventilation refers to decreased ventilation, not specifically related to fluid in the alveoli. Choice D is incorrect as fluid in the alveoli is not a direct indicator of heart failure.
Question 4 of 9
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 5 of 9
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 6 of 9
The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Remove the patient's rings first. This is crucial to prevent constriction and swelling due to potential allergic reactions or inflammation from bee stings. Removing rings allows for proper circulation and prevents complications like compartment syndrome. Ice packs (B) can be applied after removing the rings to reduce swelling. Calamine lotion (C) can provide relief for itching but is not as urgent as ring removal. Diphenhydramine (D) can be given later for systemic allergic reactions but should not take precedence over removing the rings.
Question 7 of 9
A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent?
Correct Answer: A
Rationale: The correct answer is A: Obtain the permission of the custodial parent for the surgery. In this scenario, the client is a minor (16 years old), which means they are not legally able to provide informed consent for medical procedures. The custodial parent holds legal responsibility for the minor's healthcare decisions. Thus, obtaining the permission of the custodial parent is crucial to ensure valid informed consent. Choice B is incorrect because the non-custodial parent's consent may not be legally required if the custodial parent is available to provide consent. Choice C is incorrect because obtaining consent should precede any administration of medications. Choice D is incorrect as the stepfather's consent may not hold legal weight unless designated as a legal guardian.
Question 8 of 9
The nurse is assessing the patient’s pain using the Critical Care Pain Observation Tool (CPOT). Which of the following assessments would indicate the greatest likelihood of pain and need for nursing intervention?
Correct Answer: B
Rationale: The correct answer is B: Fighting the ventilator. This behavior indicates the patient is experiencing discomfort and struggling against the ventilator, suggesting a high likelihood of pain. The CPOT assesses pain through behaviors like grimacing, vocalization, and muscle tension, which are all present when a patient is fighting the ventilator. Absence of vocal sounds (Choice A) does not necessarily indicate pain as some patients may be silent even when in pain. Moving legs in bed (Choice C) could be due to restlessness rather than pain. Relaxed muscles in upper extremities (Choice D) do not reflect pain as the CPOT focuses on behaviors indicating discomfort.
Question 9 of 9
The nurse is educating a patient’s family member about a pulmonary artery catheter (PAC). Which statement by the family member best indicates undaebrisrbt.acnomd/itnesgt of the purpose of the PAC?
Correct Answer: B
Rationale: The correct answer is B because it shows understanding that the PAC helps in managing fluid therapy effectively. The PAC measures pressures in the heart and lungs, guiding fluid management. Choice A is incorrect as the PAC is not primarily for IV fluid administration. Choice C shows understanding of the catheter placement but not its purpose. Choice D is incorrect as the PAC is not for the heart to heal but to monitor cardiac status.