ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 of 5
The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will be most effective in addressing this problem?
Correct Answer: D
Rationale: The correct answer is D: Instill 5 mL of sterile saline into the ET before suctioning. This intervention helps to loosen and mobilize the thick secretions, making them easier to remove during suctioning. It is important to moisten the secretions to prevent mucosal damage and trauma during suctioning. A: Increasing suctioning frequency can lead to mucosal damage and increased risk of infection. B: Repositioning helps with ventilation and preventing pressure injuries, but it does not directly address the thick secretions. C: Adding water to enteral feedings will not directly address the thick secretions in the ET. In summary, instilling sterile saline into the ET before suctioning is the most effective intervention as it helps to loosen and mobilize thick secretions, making suctioning more effective and reducing the risk of mucosal damage.
Question 2 of 5
The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education?
Correct Answer: D
Rationale: The correct answer is D because positioning the patient with the head of the bed at 10 degrees is incorrect for a patient receiving mechanical ventilation. The optimal position for such patients is to elevate the head of the bed to 30-45 degrees to prevent aspiration and improve oxygenation. Option A is incorrect as increasing FIO2 before suctioning is appropriate to ensure adequate oxygenation. Option B is incorrect as securing a bite block in place using adhesive tape is a standard practice to prevent the patient from biting on the endotracheal tube. Option C is incorrect as asking for assistance to reposition the endotracheal tube shows the RN is aware of the importance of proper placement to ensure effective ventilation.
Question 3 of 5
After the change-of-shift report, which patient should the progressive care nurse assess first?
Correct Answer: D
Rationale: The correct answer is D. The patient receiving IV heparin with a PTT of 98 seconds is at risk for bleeding due to the therapeutic range of 60-80 seconds. Assessing this patient first is crucial to prevent potential bleeding complications. A high PTT indicates the blood is not clotting properly, increasing the risk of bleeding. Prompt assessment and possible adjustment of heparin infusion are needed. A: The patient with a temperature of 101.4°F may have a fever but is not at immediate risk compared to the patient with a high PTT. B: The patient on BiPAP with a respiratory rate of 16 is stable and does not require immediate assessment. C: The patient post-percutaneous coronary intervention needing to void is a routine need and does not require immediate attention compared to the patient with a critical lab value.
Question 4 of 5
A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should:
Correct Answer: B
Rationale: The correct answer is B: Obtain a Glasgow Coma Scale score. During the primary survey, assessing the patient's level of consciousness is crucial as it helps determine the severity of the injury and guides further management. The Glasgow Coma Scale is a standardized tool used to assess the level of consciousness based on eye opening, verbal response, and motor response. It provides valuable information about the patient's neurological status. A: Obtaining a complete set of vital signs is important but assessing the level of consciousness takes priority in this scenario. C: Asking about chronic medical conditions is important but not as critical as assessing the patient's level of consciousness during the primary survey. D: Attaching a cardiac electrocardiogram monitor is not necessary during the primary survey unless there are specific indications of cardiac issues, which are not evident in this case. In summary, obtaining a Glasgow Coma Scale score is essential for assessing the patient's level of consciousness and determining the severity of the injury during the primary survey.
Question 5 of 5
When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87°F (30.6°C), which assessment indicates that the nurse should discontinue active rewarming?
Correct Answer: D
Rationale: The correct answer is D. When rewarming a hypothermic patient, the goal is to gradually increase their core temperature. A core temperature of 94°F (34.4°C) is still below the normal range, but it indicates that the rewarming process is working. Shivering (A) is a normal response to rewarming. A decrease in blood pressure (B) may be expected due to peripheral vasodilation during rewarming. Developing atrial fibrillation (C) may be a concern but does not necessarily indicate that rewarming should be discontinued. Therefore, choice D is correct as it signifies progress in the rewarming process.