ATI RN
Critical Care Nursing Practice Questions Questions
Question 1 of 5
What is the best way to monitor agitation and effectivenes s of treating it in the critically ill patient?
Correct Answer: D
Rationale: The correct answer is D: Richmond Agitation Sedation Scale (RASS). RASS is specifically designed to monitor agitation and sedation levels in critically ill patients, providing a standardized and objective assessment. It includes clear descriptors for different levels of agitation and sedation, allowing for consistent monitoring and treatment adjustments. CAM-ICU is mainly used for delirium assessment, not agitation. FACES assessment tool is more appropriate for pain assessment. Glasgow Coma Scale is focused on assessing level of consciousness, not agitation specifically. By using RASS, healthcare providers can accurately track agitation levels and evaluate the effectiveness of interventions in managing agitation in critically ill patients.
Question 2 of 5
Which of the following statements regarding pain and anxiety are true? (Select all that apply.)
Correct Answer: A
Rationale: Rationale: A: Correct. Anxiety is characterized by apprehension, agitation, autonomic arousal, and fearful withdrawal, which are distinct from pain. B: Incorrect. Critically ill patients can experience both anxiety and pain, as pain is not exclusive to them. C: Incorrect. While pain and anxiety can be interrelated, they can be differentiated based on their unique physiological and behavioral manifestations. D: Incorrect. Pain is a subjective experience, but it is not solely defined by the individual; objective assessments are also important.
Question 3 of 5
The nurse is caring for a 48-year-old patient who is intubated and on a ventilator following extensive abdominal surgery. Although the patient is respo nsive, the nurse is not able to read the patient’s lips as the patient attempts to mouth the words. Which of the following assessment tools would be the most appropriate for the nu rse to use when assessing the patient’s pain level? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: The FACES scale. This scale uses facial expressions to assess pain, making it suitable for a patient who is unable to verbalize. The nurse can show the patient a series of faces depicting varying levels of pain and ask them to point to the one that best represents their pain level. This method is non-verbal and easy for patients to understand. The other choices are incorrect: B: The Pain Intensity Scale requires the patient to rate their pain on a numerical scale, which may be difficult for a non-verbal patient. C: The PQRST method is a mnemonic for assessing pain characteristics (provocation, quality, region, severity, timing), but it requires patient communication. D: The Visual Analogue Scale involves marking a point on a line to indicate pain intensity, which is not suitable for a non-verbal patient.
Question 4 of 5
After coronary artery bypass graft surgery a patient is transported to the surgical intensive care unit at noon and placed on mechanical ventilation. How sh ould the nurse interpret the patient’s initial arterial blood gas levels? pH 7.31 PaCO 48 mm Hg Bicarbonate 22 mEq/L PaO 115 mm Hg O saturation 99%
Correct Answer: B
Rationale: The correct answer is B: Partly compensated respiratory acidosis, normal oxygen. The pH of 7.31 indicates acidosis, the PaCO2 of 48 mm Hg shows respiratory acidosis, and the bicarbonate level of 22 mEq/L is slightly elevated, indicating the kidneys are compensating. The PaO2 of 115 mm Hg and oxygen saturation of 99% are normal, ruling out hypoxemia. Therefore, the patient is experiencing partly compensated respiratory acidosis. A: Normal arterial blood gas levels with a high oxygen level - Incorrect. The pH is low, indicating acidosis, which is not normal. C: Uncompensated metabolic acidosis with high oxygen level - Incorrect. Metabolic acidosis would have a primary issue with bicarbonate levels, which is not the case here. D: Uncompensated respiratory acidosis; hyperoxygenated - Incorrect. The oxygen levels are normal, ruling out hyperoxygenation.
Question 5 of 5
When it is noted that a patient’s endotracheal tube is not se cured tightened, he respiratory care practitioner assists the nurse in taping the tube. After the tu be is retaped, the nurse auscultates the patient’s lungs and notes that the breath sounds over the left lung fields are absent. The nurse suspects is the cause of this finding?
Correct Answer: A
Rationale: The correct answer is A: The endotracheal tube is in the right mainstem bronchus. When the endotracheal tube is not secured properly and is retaped, there is a possibility that it may have migrated into the right mainstem bronchus, leading to absent breath sounds in the left lung fields. This condition is known as endobronchial intubation. In such cases, ventilation primarily occurs in the right lung, resulting in decreased or absent breath sounds on the contralateral side. Choices B, C, and D are incorrect as they do not explain the absence of breath sounds over the left lung fields in this specific scenario.