ATI RN
Critical Care Nursing Questions Questions
Question 1 of 5
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 2 of 5
When caring for a patient who has an arterial catheter in the left radial artery for arterial pressure-based cardiac output (APCO) monitoring, which information obtained by the nurse is most important to report to the health care provider?
Correct Answer: B
Rationale: The correct answer is B: There is redness at the catheter insertion site. Redness at the catheter insertion site could indicate infection, which is a serious complication that requires immediate attention to prevent sepsis. Reporting this to the healthcare provider promptly is crucial for timely intervention. Choices A, C, and D are not as urgent. A positive Allen test (choice A) assesses collateral circulation and is important for assessing perfusion before arterial cannulation but does not require immediate intervention. Choice C (MAP is 86 mm Hg) falls within the normal range, so it does not indicate an urgent issue. The visibility of the dicrotic notch in the arterial waveform (choice D) is a normal finding and does not require immediate action.
Question 3 of 5
The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the healthcare provider immediately if the patient develops:
Correct Answer: D
Rationale: The correct answer is D: Increased jugular venous distention. In a patient with a subarachnoid hemorrhage and on mechanical ventilation, increased jugular venous distention can indicate increased intracranial pressure, which can be life-threatening. The nurse should notify the healthcare provider immediately as it may require urgent intervention to prevent further neurological deterioration. A: Oxygen saturation of 93% is within the acceptable range for a patient on mechanical ventilation and may not require immediate notification. B: Respirations of 20 breaths/minute are within normal limits for a ventilated patient and do not necessarily indicate a critical condition. C: Green nasogastric tube drainage may indicate the presence of bile and could be related to gastrointestinal issues, but it does not pose an immediate threat to the patient's neurological status.
Question 4 of 5
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next?
Correct Answer: B
Rationale: Rationale: The correct action is to observe the patient's respiratory effort next. This step ensures that the patient's breathing remains stable and adequate. If respiratory effort is compromised, immediate intervention is required. Checking for bilateral pulses (A) is important but comes after ensuring respiratory status. Checking level of consciousness (C) is also crucial but not as immediate as monitoring breathing. Examining for external bleeding (D) is important but not the priority when airway and breathing are already determined to be clear.
Question 5 of 5
A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement?
Correct Answer: C
Rationale: The correct answer is C: "I should drink sports drinks when working outside in hot weather." This statement is correct because hypotension and elevated temperature could indicate dehydration and electrolyte imbalance due to excessive sweating in hot weather. Drinking sports drinks can help replenish electrolytes lost through sweating and prevent dehydration. Incorrect choices: A: Taking salt tablets can lead to an imbalance in electrolytes and worsen the condition. B: Acetaminophen can lower fever but does not address dehydration or electrolyte imbalance. D: Moving to a cool environment when feeling confused is important but does not address the underlying issue of dehydration and electrolyte imbalance.