ATI RN
Critical Care Nursing Questions Questions
Question 1 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 2 of 9
A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, 'I had a temperature of 103.9°F (39.9°C) at home.' The nurse’s first action should be to:
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's current vital signs. The nurse's first action should be to gather objective data to assess the patient's condition and determine the urgency of the situation. Vital signs, including temperature, heart rate, blood pressure, and respiratory rate, provide crucial information for the initial assessment. This will help the nurse identify any signs of sepsis, shock, or other serious conditions that require immediate intervention. The other choices are incorrect because: B: Giving acetaminophen without assessing the patient's vital signs and determining the cause of the symptoms could mask important clinical information and delay appropriate treatment. C: While obtaining a urine sample may be necessary later to rule out a urinary tract infection, it is not the most immediate priority in this case. D: Delaying the patient's assessment and care based on estimated wait times is not appropriate when the patient presents with potentially serious symptoms. Immediate evaluation is required in this scenario.
Question 3 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 4 of 9
The nurse caring for a critically ill patient implements several components of care. What component is an example of the use of evidence-based practice?
Correct Answer: B
Rationale: The correct answer is B because applying an insulin sliding scale method based on research is an example of evidence-based practice. This method is derived from scientific evidence and research studies, ensuring the best outcomes for the patient. The other choices lack the same level of evidence-based rationale: A is based on a protocol, which may not be evidence-based; C is a standard safety practice, not necessarily evidence-based; D is a decision based on hospital policy or practicality, not specifically evidence-based.
Question 5 of 9
Following insertion of a pulmonary artery catheter (PAC),a bthirbe. cpohmy/tessitc ian orders the nurse to obtain a blood sample for mixed venous oxygen saturation (SvO ). Which action by the nurse best ensures the obtained value is accurate?
Correct Answer: B
Rationale: The correct answer is B because calibrating the system with central venous and arterial blood samples ensures accuracy of the mixed venous oxygen saturation (SvO2) measurement. This calibration allows for comparison of the values obtained from both sources to confirm the accuracy of the measurement. Choice A is incorrect because zero referencing the transducer at the level of the phlebostatic axis does not directly address the accuracy of the SvO2 measurement. Choice C is incorrect because ensuring patency of the catheter using normal saline pressurized at 300 mm Hg does not directly impact the accuracy of the SvO2 measurement. Choice D is incorrect because using noncompliant pressure tubing does not ensure the accuracy of the SvO2 measurement. The length of the tubing and the presence of stopcocks are not directly related to obtaining an accurate SvO2 value.
Question 6 of 9
The family of a critically ill patient has asked to discuss organ donation with the patient’s nurse. When preparing to answer the family’s questions, th e nurse understands which concern(s) most often influence a family’s decision to donate? (Select all that apply.)
Correct Answer: A
Rationale: Rationale for Correct Answer A: Donor disfigurement influences on funeral care. Families often consider the impact of organ donation on the appearance of their loved one during funeral arrangements. This concern can significantly influence their decision to donate. Incorrect Answers: B: Fear of inferior medical care provided to donor. This is not a common concern as medical care for donors is typically of high quality. C: Age and location of all possible organ recipients. While important, this is not a primary concern for families when deciding on organ donation. D: Concern that donated organs will not be used. Families are generally more concerned about the impact on their loved one's appearance post-donation rather than the utilization of organs.
Question 7 of 9
What were identified as the first critical care units? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Burn units. Burn units were identified as the first critical care units due to the complex and intensive care required by burn patients. These units were established to provide specialized care for burn victims, including wound management, infection control, and fluid resuscitation. Summary: - Burn units were the first critical care units due to the specialized care needed for burn patients. - Coronary care units focus on cardiac conditions, not the first identified critical care units. - Recovery rooms are for post-operative care, not specifically for critical care. - Neonatal intensive care units are specialized for newborns, not the first critical care units.
Question 8 of 9
The patient has just returned from having an arteriovenous fistula placed. The patient asks, “When will they be able to use this and take this other catheter out?” The nurse should reply,
Correct Answer: C
Rationale: The correct answer is C: “The fistula will be usable in about 4 to 6 weeks.” The rationale for this is that an arteriovenous fistula typically requires 4 to 6 weeks to mature and be ready for use. During this time, the fistula develops the necessary blood flow for efficient dialysis. Choice A is incorrect because immediate use of the fistula is not recommended as it needs time to mature. Choice B is incorrect as it underestimates the time needed for the fistula to heal and mature. Choice D is incorrect as the usability of the fistula is not dependent on the manufacturer but rather on the patient's individual healing process.
Question 9 of 9
A client has been admitted after experiencing multiple trauma and is intubated and sedated. When the five members of the immediate family arrive, they are anxious, angry, and very demanding. They all speak loudly at once and ask for many services and answers. What is the best nursing response?
Correct Answer: B
Rationale: The correct answer is B: Take them to a private area for initial explanations. This response is the best because it allows the nurse to address the family's concerns in a private and controlled environment. It promotes effective communication and enables the family to express their emotions and receive information without distractions. Choice A is incorrect because asking the family to leave may escalate the situation and not address their needs. Choice C is inappropriate as paging security to remove the family can worsen the family's distress and hinder communication. Choice D is not ideal as leaving the family alone may lead to misunderstandings and increased anxiety. Overall, choice B is the most therapeutic and effective approach in this situation.