ATI RN
Critical Care Nursing Questions Questions
Question 1 of 9
The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis?
Correct Answer: B
Rationale: The correct answer is B: Train-of-four yields two twitches. This assessment indicates a target level of paralysis because a train-of-four ratio of 2 twitches out of 4 suggests a 50% neuromuscular blockade, which is often the goal for patients receiving paralysis for procedures or ventilation. A: A Glasgow Coma Scale score of 3 assesses consciousness, not neuromuscular blockade. C: A Bispectral index of 60 measures depth of anesthesia, not paralysis level. D: CAM-ICU assesses delirium, not neuromuscular blockade.
Question 2 of 9
A child is receiving maintenance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg of body weight, plus 50 mL/kg per day for each kilogram between 10 and 20. How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg?
Correct Answer: B
Rationale: To calculate the IV fluids for a 19.5 kg child: 1. For the first 10 kg: 1000 mL 2. For the weight between 10-20 kg: (19.5 kg - 10 kg) * 50 mL/kg = 475 mL Total IV fluids = 1000 mL + 475 mL = 1475 mL To convert to mL per hour: 1475 mL / 24 hours = ~61 mL/hr Therefore, the correct answer is B (61 mL/hr). Incorrect Choices: A (24 mL/hr): Incorrect, as it doesn't consider the additional fluids for the weight between 10-20 kg. C (73 mL/hr) and D (58 mL/hr): Incorrect, as these values are not obtained from the correct calculation based on the given formula.
Question 3 of 9
Slow continuous ultrafiltration is also known as isolated ultrafiltration and is used to
Correct Answer: A
Rationale: The correct answer is A because slow continuous ultrafiltration removes excess plasma water in cases of volume overload by applying a pressure gradient across a semipermeable membrane. This process helps to achieve fluid balance without removing solutes. Choice B is incorrect because convection is not the primary mechanism of slow continuous ultrafiltration. Choice C is incorrect as dialysate is not added in slow continuous ultrafiltration. Choice D is incorrect as slow continuous ultrafiltration does not combine all three processes of ultrafiltration, convection, and dialysis.
Question 4 of 9
To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should:
Correct Answer: D
Rationale: The correct answer is D because inflating the cuff until a slight leak is heard only at peak inflation ensures it is adequately sealed but not overinflated, preventing complications like tracheal injury or pressure necrosis. Choice A lacks specificity and can lead to overinflation. Choice B may result in overinflation as the firmness of the balloon is subjective. Choice C relies on a specific pressure reading, which may vary based on factors like tube size and patient anatomy, potentially leading to under- or overinflation.
Question 5 of 9
In calculating the glomerular filtration rate (GFR) results for women, the creatinine clearance is usually:
Correct Answer: C
Rationale: The correct answer is C: multiplied by 0.85. This is because women typically have lower muscle mass compared to men, resulting in lower creatinine production. Therefore, to adjust for this difference, the creatinine clearance for women is multiplied by 0.85. This correction factor helps to more accurately estimate the GFR in women. Choices A and B are incorrect because the creatinine clearance for women is not the same as or greater than that for men due to the physiological differences in muscle mass. Choice D is also incorrect as multiplying by 1.15 would overestimate the GFR in women.
Question 6 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.
Question 7 of 9
Which therapeutic interventions may be withdrawn or withabhirebl.dco mfr/otemst the terminally ill client? (Select all that apply.)
Correct Answer: B
Rationale: The correct answer is B: Dialysis. In the context of terminally ill clients, withdrawing dialysis is appropriate as it can be burdensome without providing significant benefit towards the end of life. Dialysis does not cure terminal conditions and can prolong suffering unnecessarily. Antibiotics (A) may be necessary for managing infections in terminally ill clients. Nutrition (C) is important for comfort and quality of life. Pain medications (D) are essential for managing pain and should not be withdrawn unless no longer beneficial or requested by the patient.
Question 8 of 9
A patient in the ICU is complaining that he is not sleeping well at night because of anxiety. Which of the following would be the most helpful intervention for the nurse to make?
Correct Answer: C
Rationale: Rationale: C: Providing the patient with 5 minutes of effleurage (gentle massage) and minimizing disruptions is the most helpful intervention. Effleurage can help reduce anxiety and promote relaxation, improving sleep quality. Minimizing disruptions creates a conducive environment for sleep. A: Providing a bath after REM sleep may disrupt the patient's sleep cycle, worsening anxiety. B: Increasing pain medication may not address the root cause of anxiety and could lead to dependency or side effects. D: Monitoring brain waves with polysomnography is an invasive procedure not typically indicated for managing anxiety-related sleep issues.
Question 9 of 9
The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment?
Correct Answer: B
Rationale: The correct answer is B: Medication administration. This is the priority because medication administration is time-sensitive and crucial for patient safety. It requires precise timing and cannot be delayed. Tracheostomy tube suctioning (A), colostomy care instruction (C), and client personal hygiene (D) are important nursing activities but can be adjusted within the schedule based on patient needs and acuity levels. Prioritizing medication administration ensures that patients receive their medications on time, preventing adverse events and promoting optimal health outcomes.