ATI RN
Critical Care Nursing NCLEX Questions Questions
Question 1 of 9
Upon entering the room of a patient with a right radial arte rial line, the nurse assesses the waveform to be slightly dampened and notices blood to bea bbirabc.ckoemd/te ustp into the pressure tubing. What is the best action by the nurse?
Correct Answer: B
Rationale: The correct answer is B: Disconnect the flush system from the arterial line catheter. This action is necessary to prevent air from entering the patient's bloodstream, which can lead to air embolism. By disconnecting the flush system, the nurse stops the flow of air and ensures patient safety. Checking the inflation volume of the pressurized bag (A) is not the immediate concern in this situation. Zero referencing the transducer system (C) is unrelated to the issue of air entering the arterial line. Reducing the number of stopcocks in the flush system tubing (D) does not address the immediate risk of air embolism.
Question 2 of 9
A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma?
Correct Answer: D
Rationale: The correct answer is D, Metoprolol tartrate (Lopressor). Metoprolol is a cardioselective beta-blocker that primarily targets beta-1 receptors in the heart, making it less likely to exacerbate asthma compared to non-selective beta-blockers like Propranolol (choice B) and Pindolol (choice C). Carteolol (choice A) is also a non-selective beta-blocker and can potentially worsen asthma symptoms. Metoprolol's selectivity for beta-1 receptors minimizes bronchoconstriction, making it the safest choice for a client with asthma and high blood pressure.
Question 3 of 9
Which findings have been reported in the literature as benefits of allowing family to be present during resuscitation and invasive procedures? (Selaebcirtb a.clolm t/hteastt apply.)
Correct Answer: A
Rationale: Step 1: Families benefit by witnessing that everything possible was done during resuscitation and invasive procedures. Step 2: This reassures families that healthcare providers are doing their best to save the patient. Step 3: It can provide closure and comfort to families knowing that all efforts were made. Step 4: This transparency can also help in the grieving process for families. Summary: Choice A is correct because it highlights the emotional and psychological benefits for families. Choices B, C, and D are incorrect as they do not align with the positive impacts of allowing family presence during resuscitation and invasive procedures.
Question 4 of 9
The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document that indicates a successful outcome?
Correct Answer: C
Rationale: Step 1: The objective is for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Step 2: Choice C states that the client drinks 240 mL of fluid five times during the shift, totaling 1200 mL (240 mL x 5) which exceeds the required amount. Step 3: Therefore, choice C is the correct answer as it demonstrates successful achievement of the objective by ensuring the client has ingested enough fluid within the specified time frame. Step 4: Choices A, B, and D are incorrect as they do not directly address the specific objective of fluid intake set for the client. Option A focuses on intake and output, option B relates to abdominal comfort, and option D is about voiding, none of which directly address the specified objective of fluid ingestion.
Question 5 of 9
The nurse is caring for a patient who has an intra-aortic balloon pump in place. Which action should be included in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Measure the patient’s urinary output every hour. This is crucial because monitoring urinary output is essential in assessing the patient’s renal function and the effectiveness of the intra-aortic balloon pump in improving cardiac output. Hourly measurement helps in early detection of any changes that may indicate complications. A: Positioning the patient supine at all times is not necessary and can lead to complications. B: Avoiding the use of anticoagulant medications is not appropriate as they are often necessary to prevent clot formation around the balloon pump. D: Providing a massive range of motion for all extremities is not recommended for a patient with an intra-aortic balloon pump as it can dislodge the device or cause harm.
Question 6 of 9
What is a minimally acceptable urine output for a patient weighing 75 kg?
Correct Answer: C
Rationale: The correct answer is C (80 mL/hour) because the minimum acceptable urine output for a patient is approximately 0.5-1 mL/kg/hour. For a 75 kg patient, this equates to 37.5-75 mL/hour. Therefore, an output of 80 mL/hour is within this range and is considered minimally acceptable. A: Less than 30 mL/hour is incorrect because it is below the recommended range for a 75 kg patient. B: 37 mL/hour is close to the lower end of the acceptable range, but it is not the minimum acceptable output. D: 150 mL/hour is above the recommended range and would be considered excessive for a 75 kg patient.
Question 7 of 9
A critical care unit has decided to implement several measures designed to improve intradisciplinary and interdisciplinary collaboration. In addition to an expected improvement in patient outcomes, what is the most important effect that should resultf rom these measures?
Correct Answer: C
Rationale: Rationale: - Improved collaboration enhances job satisfaction and reduces burnout, leading to increased staff retention. - Higher staff retention promotes continuity of care, improves team dynamics, and enhances patient outcomes. Summary: - A: Not directly related to collaboration, more about performance evaluation. - B: Manners may improve, but not the most important effect of collaboration. - D: Collaboration involves open communication, so less discussion in front of patients is not a positive outcome.
Question 8 of 9
The nurse uses the Situation-Background-Assessment-Recommendation (SBAR) format to communicate a change in patient status to a healthcare provider. In which order should the nurse make the following statements?
Correct Answer: B
Rationale: Step 1: Start with Background - statement B provides relevant background information about the patient's current condition and why there is a need for communication. Step 2: Move on to Situation - statement D sets the current situation where the nurse expresses concern about the patient's symptom. Step 3: Next is Assessment - statement C details the nurse's assessment findings, highlighting the critical aspects of the patient's condition. Step 4: End with Recommendation - statement A suggests the necessary action to be taken based on the assessment findings. This order ensures a clear and structured communication process. Summary: - Choice A is incorrect as the recommendation should come after providing background, situation, and assessment. - Choice C is incorrect as assessment details should precede the patient's critical condition. - Choice D is incorrect as the situation should be explained before expressing concern.
Question 9 of 9
A 75-year-old patient, who suffered a massive stroke 3 weeks ago, has been unresponsive and
Correct Answer: E
Rationale: Step 1: The scenario describes a decision made based on the patient's previously expressed wishes. Step 2: The decision aligns with the principle of respecting patient autonomy. Step 3: The term that best describes this situation is "Advance Directive." Summary: - A: Incorrect, as it involves actively ending the patient's life without their consent. - B: Incorrect, as euthanasia involves intentionally causing death to relieve suffering. - C: Incorrect, as palliative care focuses on improving quality of life for the patient. - D: Incorrect, as withdrawal of life support involves discontinuing medical interventions, not honoring the patient's wishes.