ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 of 5
The son of a dying patient tells the nurse, 'Mother doesn’t respond anymore when I visit. I don’t think she knows that I am here.' Which response by the nurse is appropriate?
Correct Answer: B
Rationale: The correct answer is B because withdrawal is a common psychological response in the dying process. The nurse should explain to the son that his mother's lack of response may be her way of preparing to leave life. This response validates the son's concerns while providing reassurance. Choice A is incorrect because cutting back visits may not address the underlying issue of the mother's withdrawal. Choice C is incorrect because stimulating the mother may not be beneficial or appropriate in this situation. Choice D is incorrect because not all patients experience a lack of awareness at the end of life, and assuming so may not be helpful in this context.
Question 2 of 5
As part of the admission process, the nurse asks several questions about family relationships. The nurse bases these actions on which rationale?
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct: 1. Involving the family in patient care is crucial for holistic care. 2. Assessing family relationships helps identify support systems and potential conflicts. 3. Understanding family dynamics aids in creating a comprehensive care plan. 4. Family involvement can enhance patient outcomes and satisfaction. Summary of incorrect choices: B. Irrelevant, as the focus is on patient-centered care, not just fulfilling an assessment tool. C. Personal curiosity is not a valid reason for assessing family relationships in healthcare. D. Conducting research on family patterns does not directly impact the immediate care of the patient.
Question 3 of 5
A nurse in a burn unit observes that a patient is tensed up and frowning but silent. The nurse asks the patient, Can you tell me what you are thinking now? The patient responds, I cant take this pain any more! I feel like Im about to die. What would be the best response for the nurse to give to the patient, considering that the patient is already receiving the maximum amount pain medication that is safe?
Correct Answer: C
Rationale: The correct response is C: Your pain medication is already at the highest possible dose. This response acknowledges the patient's pain and reassures them that they are already receiving the maximum safe amount of pain medication. By stating this, the nurse is validating the patient's experience and showing empathy. It is important for the nurse to communicate clearly about the medication to manage the patient's expectations. Choice A is incorrect as it dismisses the patient's pain and can come across as insensitive. Choice B may be well-intentioned but does not address the immediate concern of the patient's pain. Choice D is irrelevant to the patient's statement about pain and does not offer any immediate support or reassurance regarding the pain management.
Question 4 of 5
A patient is admitted to the hospital with multiple trauma aabnirdb .ceoxmte/tensst ive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vas cular resistance of 3000 dynes/sec/cm5, and a hematocrit of 20%. The nurse anticip ates administration of which the following therapies or medications?
Correct Answer: C
Rationale: The correct answer is C: Dobutamine infusion. In this scenario, the patient is experiencing hypovolemic shock due to significant blood loss, resulting in low blood pressure, tachycardia, and low cardiac output. Dobutamine is a positive inotropic agent that increases cardiac contractility and output, helping to improve tissue perfusion. Blood transfusion (A) is a common intervention for hypovolemic shock, but in this case, the patient's hematocrit is low, indicating dilutional anemia rather than acute blood loss, so addressing the cardiac output is more urgent. Furosemide (B) is a diuretic that would exacerbate the hypovolemia and worsen the patient's condition. Dopamine (D) is a vasopressor that primarily increases blood pressure, but in this case, the patient's low cardiac output is the main concern, making dobutamine a more appropriate choice.
Question 5 of 5
The nurse uses subtle measures of painful stimuli, such as nailbed pressure to elicit a response from a neurologically impaired patient. By using this meth od rather than nipple pinching, the nurse is exemplifying what ethical principle?
Correct Answer: C
Rationale: The correct answer is C: Nonmaleficence. The nurse is demonstrating nonmaleficence by choosing a less harmful method (nailbed pressure) to assess pain in a neurologically impaired patient, instead of a more painful method (nipple pinching). Nonmaleficence is the ethical principle of avoiding harm or minimizing harm to the patient. In this scenario, the nurse is prioritizing the well-being and comfort of the patient by using a less invasive and painful method to elicit a response. Choices A, B, and D are incorrect because beneficence refers to doing good for the patient, fidelity to being loyal and maintaining trust, and veracity to truthfulness and honesty, none of which directly apply in this situation.