ATI RN
Critical Care Nursing Exam Questions Questions
Question 1 of 5
The nurse notes premature ventricular contractions (PVCs) while suctioning a patient’s endotracheal tube. Which action by the nurse is a priority?
Correct Answer: C
Rationale: The correct answer is C: Stop and ventilate the patient with 100% oxygen. This is the priority action because PVCs can lead to life-threatening arrhythmias and inadequate oxygenation. By stopping suctioning and providing 100% oxygen, the nurse ensures proper oxygenation and ventilation, which takes precedence over addressing the dysrhythmia itself. Decreasing suction pressure (choice A) may not address the underlying issue and could potentially harm the patient. Documenting the dysrhythmia (choice B) is important but not as urgent as ensuring adequate oxygenation. Giving antidysrhythmic medications (choice D) should be done under the direction of a healthcare provider and is not the first-line intervention in this situation.
Question 2 of 5
The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take next?
Correct Answer: D
Rationale: The correct action is D: Manually ventilate the patient with 100% oxygen. This is crucial to ensure adequate oxygenation and prevent hypoxia. Holding the ET tube can lead to extubation and airway compromise. Activating the rapid response team (A) may delay immediate intervention. Providing reassurance (B) is important but not the priority in this situation. Calling the health care provider (C) to reinsert the tube would also lead to a delay in providing essential respiratory support.
Question 3 of 5
A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most important to discuss with the health care provider before starting the SBT?
Correct Answer: A
Rationale: The correct answer is A: New ST segment elevation is noted on the cardiac monitor. This finding is concerning because it may indicate myocardial ischemia or infarction, which can be exacerbated by the physiological stress of weaning from mechanical ventilation. It is crucial to address any cardiac issues before initiating a spontaneous breathing trial to prevent potential cardiac complications during the weaning process. Explanation for why the other choices are incorrect: B: Enteral feedings being given through an orogastric tube are not contraindicated for starting a spontaneous breathing trial. C: Scattered rhonchi heard when auscultating breath sounds may indicate retained secretions but are not a contraindication for a spontaneous breathing trial. D: The use of HYDROmorphone to treat postoperative pain is not a contraindication for a spontaneous breathing trial unless it is causing respiratory depression, which would need to be addressed separately.
Question 4 of 5
During the primary survey of a patient with severe leg trauma, the nurse observes that the patient’s left pedal pulse is absent and the leg is swollen. Which action will the nurse take next?
Correct Answer: B
Rationale: The correct answer is B: Assess further for a cause of the decreased circulation. The nurse should prioritize assessing the cause of the absent left pedal pulse and leg swelling to address the severe leg trauma effectively. This step involves identifying potential vascular compromise or compartment syndrome, which are critical conditions requiring immediate intervention. Sending blood for a complete blood count (A) is not the priority in this situation. Finishing the primary survey (C) may delay addressing the circulation issue. Starting normal saline infusion (D) without addressing the circulation problem first could potentially worsen the condition. Therefore, assessing further for the cause of decreased circulation is the most appropriate next step to ensure timely and appropriate management of the patient's condition.
Question 5 of 5
A 22-year-old patient who experienced a near-drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?
Correct Answer: C
Rationale: The correct answer is C: Auscultate breath sounds. After a near-drowning incident, the main concern is potential respiratory complications such as aspiration pneumonia or pulmonary edema. Auscultating breath sounds will help the nurse assess for any signs of respiratory distress or complications. This assessment is crucial for early detection and intervention. A: Auscultating heart sounds is important but not as crucial as assessing breath sounds in this scenario. B: Palpating peripheral pulses is important for circulation assessment but does not address the immediate concern of respiratory complications. D: Checking pupil reaction to light is more relevant for neurological assessment and not as critical as assessing breathing in this situation.