ATI RN
Critical Care Nursing Exam Questions Questions
Question 1 of 5
The nurse is concerned that the patient will pull out the en dotracheal tube. As part of the nursing management, the nurse should obtain an order for what intervention?
Correct Answer: A
Rationale: The correct answer is A. A Posey-type vest is a restraint designed to prevent patients from pulling out medical devices like endotracheal tubes, ensuring their safety. It is a less restrictive option compared to wrist restraints and sedatives (B and C), which can have adverse effects and may not directly address the concern of tube removal. Using a Posey-type vest promotes patient autonomy by allowing some movement while still providing the necessary protection.
Question 2 of 5
The nurse is caring for a patient receiving benzodiazepine intermittently. What is the best way to administer such drugs?
Correct Answer: D
Rationale: The correct answer is D: Titrate to a predefined endpoint using a standard sedation scale. This approach ensures individualized dosing based on the patient's response, minimizing the risk of over-sedation or under-treatment. It allows for careful monitoring and adjustment of dosage to achieve the desired level of sedation while avoiding adverse effects. A: Administering medication around the clock may lead to unnecessary sedation and increased risk of side effects. B: Administering medications through a feeding tube is not recommended for benzodiazepines as it may affect absorption and increase the risk of complications. C: Giving the highest allowable dose without considering individual response can result in excessive sedation and adverse effects.
Question 3 of 5
Anxiety differs from pain in that way? (Select all that app ly.)
Correct Answer: B
Rationale: The correct answer is B because anxiety is indeed linked to reward and punishment centers in the limbic system, specifically involving the amygdala and prefrontal cortex. This connection influences emotional responses and behaviors related to anxiety. Choices A, C, and D are incorrect because anxiety involves both neurological and psychological processes beyond the brain, is highly subjective like pain, and can lead to physical symptoms without actual tissue injury.
Question 4 of 5
The nurse is caring for a postoperative patient in the critica l care unit. The physician has ordered patient-controlled analgesia (PCA) for the patient. The nurse understands what facts about the PCA? (Select all that apply.)
Correct Answer: A
Rationale: Step-by-step rationale for why Answer A is correct: 1. Patient-controlled analgesia (PCA) allows patients to self-administer pain medication within preset limits, promoting pain management. 2. PCA is considered safe and effective as it provides better pain control, reduces the risk of overdose, and allows for individualized dosing. 3. Healthcare providers can monitor and adjust the PCA settings as needed to ensure optimal pain relief. 4. Studies have shown that PCA is a preferred method for postoperative pain management due to its efficacy and safety profile. 5. Overall, PCA is a reliable and beneficial approach to analgesia administration in postoperative patients. Summary of why other choices are incorrect: B: While PCA may have fewer side effects compared to some routes, this is not a defining characteristic of PCA. C: While patients do have some control over their treatment with PCA, the primary focus is on pain management rather than giving control to critically ill patients. D: PCA can be used effectively without family
Question 5 of 5
The nurse caring for a patient with an endotracheal tube un derstands that endotracheal suctioning is needed to facilitate removal of secretions. What additional information is the nurse aware of concerning this intervention?
Correct Answer: C
Rationale: Rationale for Correct Answer C: Endotracheal suctioning should be done as indicated by patient assessment because not all patients require routine suctioning. Performing unnecessary suctioning can lead to potential complications such as mucosal damage and increased risk of infection. Therefore, the nurse must assess the patient's respiratory status, auscultate lung sounds, monitor oxygen saturation levels, and observe for signs of increased secretions before deciding to perform suctioning. Summary of Incorrect Choices: A: Endotracheal suctioning does not directly impact intracranial pressure. It is primarily focused on maintaining airway patency and removing respiratory secretions. B: While endotracheal suctioning may temporarily suppress the cough reflex during the procedure, its primary purpose is to clear airway secretions to prevent complications such as atelectasis and respiratory distress. D: Saline instillation before suctioning is not recommended as it can lead to negative outcomes such as dehydration, mucosal damage, and increased risk of infection