ATI RN
Critical Care Nursing Questions Questions
Question 1 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 2 of 5
A patient in the ICU is complaining that he is not sleeping well at night because of anxiety. Which of the following would be the most helpful intervention for the nurse to make?
Correct Answer: C
Rationale: Rationale: C: Providing the patient with 5 minutes of effleurage (gentle massage) and minimizing disruptions is the most helpful intervention. Effleurage can help reduce anxiety and promote relaxation, improving sleep quality. Minimizing disruptions creates a conducive environment for sleep. A: Providing a bath after REM sleep may disrupt the patient's sleep cycle, worsening anxiety. B: Increasing pain medication may not address the root cause of anxiety and could lead to dependency or side effects. D: Monitoring brain waves with polysomnography is an invasive procedure not typically indicated for managing anxiety-related sleep issues.
Question 3 of 5
The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action?
Correct Answer: A
Rationale: The correct answer is A: Diminished breath sounds over the left lung field. This finding could indicate a pneumothorax, a serious complication of subclavian CVC insertion. Immediate action is required to prevent respiratory distress. Incorrect answers: B: Localized pain at insertion site is common post-procedure and may not indicate a serious issue. C: A central venous pressure of 5 mm Hg is within the normal range and does not require immediate action. D: Slight bloody drainage is expected initially and can be managed with routine care.
Question 4 of 5
Which treatment can be used to dissolve a thrombus that is lodged in the pulmonary artery?
Correct Answer: D
Rationale: The correct answer is D: Thrombolytics. Thrombolytics are medications that can dissolve blood clots, making them effective in treating a thrombus lodged in the pulmonary artery. They work by activating the body's natural clot-dissolving system. Aspirin (A) is an antiplatelet drug and may prevent further clot formation but cannot dissolve an existing thrombus. Embolectomy (B) is a surgical procedure to remove a clot and is invasive, usually reserved for cases where thrombolytics are contraindicated. Heparin (C) is an anticoagulant that prevents clot formation but does not dissolve existing clots like thrombolytics do.
Question 5 of 5
Which patient should the nurse notify the organ procureme nt organization (OPO) to evaluate for possible organ donation?
Correct Answer: A
Rationale: The correct answer is A because the patient is a 36-year-old with a Glasgow Coma Scale score of 3 and no activity on electroencephalogram, indicating severe brain injury and likely irreversible neurological damage. This patient meets the criteria for potential organ donation as they are neurologically devastated. Choice B is incorrect because the patient's condition is related to stroke and atrial fibrillation, not severe brain injury that would make them a candidate for organ donation. Choice C is incorrect because although the patient has a brain injury and a lower Glasgow Coma Scale score, the history of a reversible cause (ovarian cancer metastasis) and a higher GCS score compared to choice A make this patient less suitable for organ donation evaluation. Choice D is incorrect as the patient's diabetic and cardiovascular history does not suggest severe brain injury that would qualify for organ donation.
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