ATI RN
Critical Care Nursing Questions Questions
Question 1 of 9
The nurse is caring for a patient with severe neurological impairment following a massive stroke. The primary care provider has ordered tests to detearbmirbi.ncoem b/treasit n death. The nurse understands that criteria for brain death includes what crite ria? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Absence of cerebral blood flow. Brain death is determined by the irreversible cessation of all brain functions, including blood flow to the brain. When there is no cerebral blood flow, the brain is unable to function, leading to brain death. This criterion is essential in diagnosing brain death as it indicates a complete loss of brain function. Explanation for why the other choices are incorrect: - B: Absence of brainstem reflexes on neurological examination is a common sign of brain death, but it is not the primary criterion. - C: Presence of Cheyne-Stokes respirations is not indicative of brain death. It is a pattern of breathing that can be seen in various conditions, not specifically brain death. - D: Confirmation of a flat electroencephalogram is a supportive test for brain death but not the primary criterion. The absence of brain activity on an EEG can help confirm brain death but is not as definitive as the absence of cerebral blood flow.
Question 2 of 9
The nurse caring for a mechanically ventilated patient note s the high pressure alarm sounding but cannot quickly identify the cause of the alarm. The nurasbeir bn.cootme/ste stht e patient’s oxygen saturation is decreasing and heart rate and respiratory rate are increasing. What is the nurse’s priority action?
Correct Answer: B
Rationale: The correct answer is B. The nurse's priority is to ensure the patient's safety and well-being. Calling the rapid response team will allow for immediate assessment by a team of healthcare professionals to address the deteriorating condition. This step takes precedence over troubleshooting the ventilator or manually ventilating the patient. Asking for a new ventilator (A) or manually ventilating the patient (D) does not address the urgent need for a comprehensive assessment and intervention. Continuing to troubleshoot the alarm (C) can delay critical interventions needed for the patient's worsening condition. Thus, calling the rapid response team is the most appropriate action to address the escalating clinical situation promptly.
Question 3 of 9
Which intervention is appropriate to assist the patient to co pe with admission to the critical care unit?
Correct Answer: B
Rationale: The correct answer is B: Explaining all procedures in easy-to-understand terms. This intervention is appropriate as it helps reduce the patient's anxiety by providing clear information about what to expect during their stay in the critical care unit. This promotes a sense of control and understanding, which can positively impact the patient's coping mechanisms. A: Allowing unrestricted visiting by several family members at one time may overwhelm the patient and interfere with their rest and recovery. C: Providing back massage and mouth care may be beneficial but may not directly address the patient's need for information and understanding. D: Turning down the alarm volume on the cardiac monitor may provide a more comfortable environment but does not address the patient's emotional and psychological needs related to coping with admission to the critical care unit.
Question 4 of 9
A patient nearing death experiences increased secretions and noisy breathing. What is the nurse’s priority intervention?
Correct Answer: B
Rationale: The correct answer is B: Administer anticholinergic medications as prescribed. Anticholinergic medications can help dry up secretions and improve breathing in a patient nearing death. This intervention targets the underlying cause of increased secretions. Suctioning (choice A) may provide temporary relief but does not address the root issue. Elevating the head of the bed and repositioning (choice C) can help with comfort but do not directly address the secretions. Restricting oral intake (choice D) may lead to dehydration and discomfort without effectively managing the secretions. Administering anticholinergic medications is the priority as it directly targets the symptom of increased secretions, improving the patient's comfort and quality of life.
Question 5 of 9
The most common reasons for initiating dialysis in acute kidney injury include which of the following? (Select all that apply.)
Correct Answer: C
Rationale: The correct answer is C: Volume overload. In acute kidney injury, impaired kidney function leads to fluid retention, causing volume overload. Dialysis helps remove excess fluid to restore fluid balance. Acidosis and hyperkalemia are potential complications of acute kidney injury but not the primary reasons for initiating dialysis. Hypokalemia is unlikely in acute kidney injury due to impaired excretion of potassium by the kidneys. Therefore, the most common reason for initiating dialysis in acute kidney injury is to manage volume overload.
Question 6 of 9
The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the healthcare provider immediately if the patient develops:
Correct Answer: D
Rationale: The correct answer is D: Increased jugular venous distention. In a patient with a subarachnoid hemorrhage and on mechanical ventilation, increased jugular venous distention can indicate increased intracranial pressure, which can be life-threatening. The nurse should notify the healthcare provider immediately as it may require urgent intervention to prevent further neurological deterioration. A: Oxygen saturation of 93% is within the acceptable range for a patient on mechanical ventilation and may not require immediate notification. B: Respirations of 20 breaths/minute are within normal limits for a ventilated patient and do not necessarily indicate a critical condition. C: Green nasogastric tube drainage may indicate the presence of bile and could be related to gastrointestinal issues, but it does not pose an immediate threat to the patient's neurological status.
Question 7 of 9
A patients family is exhibiting increasingly impaired coping as the patients condition deteriorates. The nurse asks the family to state the biggest concern from their perspective.What is the most important rationale for this question?
Correct Answer: C
Rationale: The correct answer is C because asking the family to state their biggest concern clarifies the nurse's understanding of the current family needs. This step allows the nurse to assess the specific areas where the family may require support or assistance, leading to more tailored interventions. By identifying the primary concern, the nurse can better address the family's emotional, informational, or practical needs. Choice A is incorrect because the question is not solely about active listening; it serves a deeper purpose of assessment. Choice B is incorrect as the question goes beyond validating knowledge to understanding emotional and practical needs. Choice D is incorrect because the question focuses on identifying concerns rather than defining the degree of understanding.
Question 8 of 9
An elderly patient is admitted to the ICU with stage IV lung cancer, diabetes mellitus, and congestive heart failure. The health care team assembled to care for her is large and diverse, including an oncologist, a pulmonologist, an endocrinologist, a cardiologist, and others. The patient is not expected to survive more than a few weeks, and her husband is overwhelmed with stress and grief. Which nurse competency or competencies are most needed in this situation? Select all that apply.
Correct Answer: B
Rationale: The correct answer is B: Caring practices. In this situation, the patient and her husband are dealing with complex medical conditions and emotional distress. Caring practices involve providing compassionate, empathetic, and supportive care to the patient and her family members during this difficult time. The nurse needs to show sensitivity, understanding, and emotional support to help them cope with their situation. Clinical judgment (A) is important but not the primary focus in this scenario. Collaboration (C) is essential in the interdisciplinary team, but caring practices take precedence in addressing the emotional needs. Response to diversity (D) is also important, but in this case, the focus is more on providing compassionate care rather than addressing cultural or social diversity issues.
Question 9 of 9
Which action is best for the nurse to take to ensure culturally competent care for an alert, terminally ill Filipino patient?
Correct Answer: A
Rationale: The correct answer is A because it promotes patient-centered care by involving the patient and family in decision-making, respecting their autonomy and preferences. This approach acknowledges the importance of cultural beliefs and values in end-of-life care. Choice B undermines patient autonomy by bypassing direct communication with the patient. Choice C assumes all Filipino individuals have the same cultural needs, which is not accurate. Choice D generalizes preferences without considering individual patient needs and wishes. Overall, choice A is the most appropriate as it aligns with the principles of patient-centered care and cultural competence.