ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 of 5
The nurse is caring for four patients on the progressive car e unit. Which patient is at greatest risk for developing delirium?
Correct Answer: C
Rationale: The correct answer is C, the 86-year-old postoperative from colonic resection. This patient is at the greatest risk for delirium due to being elderly, having undergone surgery, and having a history of being from a nursing home. These factors contribute to an increased susceptibility to delirium. A: The 36-year-old with alcohol withdrawal may be at risk for delirium tremens, but the older age of the patient in choice C places them at higher risk. B: The 54-year-old with an elevated creatinine level postoperative is at risk for complications, but age and history of nursing home placement increase the risk for delirium in choice C. D: The 95-year-old with community-acquired pneumonia is at risk for delirium, but the combination of age, surgery, and nursing home history in choice C presents a greater risk.
Question 2 of 5
What is true regarding pain and anxiety in the healthy individual? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A because pain and anxiety trigger the sympathetic nervous system's fight-or-flight response, increasing heart rate, blood pressure, and stress hormones to prepare the body for potential danger. This physiological response helps the individual respond to perceived threats. Choices B, C, and D are incorrect because pain and anxiety typically increase stress levels, do not necessarily remove one from harm, and can hinder rather than enhance performance due to distraction and decreased focus.
Question 3 of 5
The nurse is assessing the critically ill patient for delirium . The nurse recognizes which characteristics that indicate hyperactive delirium? (Select aabllir bt.hcaomt /atepstp ly.)
Correct Answer: A
Rationale: The correct answer is A: Agitation. In hyperactive delirium, patients often exhibit restlessness, agitation, and hyperactivity. This behavior is a key characteristic indicating hyperactive delirium. Apathy (B), biting (C), and hitting (D) are not typically associated with hyperactive delirium. Apathy may be seen in hypoactive delirium, while biting and hitting are not specific indicators of delirium subtypes. Therefore, the correct choice is A as it aligns with the typical presentation of hyperactive delirium.
Question 4 of 5
A patient’s status deteriorates and mechanical ventilation i s now required. The pulmonologist wants the patient to receive 10 breaths/min from the ventilaabtirobr.c bomu/tt ewst ants to encourage the patient to breathe spontaneously in between the mechanical breaths at his own tidal volume. This mode of ventilation is referred to by what term?
Correct Answer: C
Rationale: Rationale: 1. Intermittent Mandatory Ventilation (IMV) allows the patient to breathe spontaneously between the preset mechanical breaths. 2. It provides a set number of breaths per minute while allowing the patient to initiate additional breaths at their own tidal volume. 3. IMV is a partial ventilatory support mode, providing a balance between controlled and spontaneous breathing. 4. Assist/Control Ventilation (A) provides full support with every breath initiated by the patient or the ventilator. 5. Controlled Ventilation (B) does not allow for spontaneous breaths by the patient. 6. Positive End-Expiratory Pressure (D) is a separate mode focusing on maintaining positive pressure at the end of expiration, not providing breaths.
Question 5 of 5
Which of the following devices is best suited to deliver 65 % oxygen to a patient who is spontaneously breathing?
Correct Answer: D
Rationale: The Venturi mask is the best choice for delivering 65% oxygen because it allows precise oxygen concentration delivery through adjustable venturi valves. This device ensures consistent oxygen levels even during variations in patient breathing patterns. Face mask with non-rebreathing reservoir (A) delivers higher oxygen concentrations, low-flow nasal cannula (B) is not suitable for precise oxygen delivery, and simple face mask (C) may not provide the desired oxygen concentration.