ATI RN
Critical Care Nursing Questions Questions
Question 1 of 9
Which intervention is appropriate to assist the patient to co pe with admission to the critical care unit?
Correct Answer: B
Rationale: The correct answer is B: Explaining all procedures in easy-to-understand terms. This intervention is appropriate as it helps reduce the patient's anxiety by providing clear information about what to expect during their stay in the critical care unit. This promotes a sense of control and understanding, which can positively impact the patient's coping mechanisms. A: Allowing unrestricted visiting by several family members at one time may overwhelm the patient and interfere with their rest and recovery. C: Providing back massage and mouth care may be beneficial but may not directly address the patient's need for information and understanding. D: Turning down the alarm volume on the cardiac monitor may provide a more comfortable environment but does not address the patient's emotional and psychological needs related to coping with admission to the critical care unit.
Question 2 of 9
Which therapeutic interventions may be withdrawn or withabhirebl.dco mfr/otemst the terminally ill client? (Select all that apply.)
Correct Answer: B
Rationale: The correct answer is B: Dialysis. In the context of terminally ill clients, withdrawing dialysis is appropriate as it can be burdensome without providing significant benefit towards the end of life. Dialysis does not cure terminal conditions and can prolong suffering unnecessarily. Antibiotics (A) may be necessary for managing infections in terminally ill clients. Nutrition (C) is important for comfort and quality of life. Pain medications (D) are essential for managing pain and should not be withdrawn unless no longer beneficial or requested by the patient.
Question 3 of 9
A patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first?
Correct Answer: C
Rationale: The correct answer is C: Body temperature. In a patient who has fallen through the ice, hypothermia is a major concern due to exposure to cold water. Assessing body temperature first is crucial to determine the severity of hypothermia and guide immediate interventions. Heart rate, breath sounds, and level of consciousness can be affected by hypothermia but are secondary assessments. Assessing body temperature is the priority to address the most life-threatening issue first.
Question 4 of 9
Which of the following are accepted nonpharmacological approaches to managing pain and/or anxiety in critically ill patients? (Select all that apply.)
Correct Answer: A
Rationale: Step 1: Environmental manipulation involves adjusting factors like lighting, noise levels, and room temperature to create a soothing environment, which can help reduce pain and anxiety. Step 2: By controlling the physical surroundings, patients may feel more comfortable and relaxed, leading to improved pain management and reduced anxiety levels. Step 3: Explanations of monitoring equipment and guided imagery are not directly related to environmental changes that can impact pain and anxiety. Step 4: Music therapy, while beneficial for some patients, is not categorized as environmental manipulation.
Question 5 of 9
A Muslim patient has been admitted to the critical care unit with complications after childbirth. Based on the Synergy Model, which nurse would be the most inappropriate to assign to care for this patient?
Correct Answer: C
Rationale: Step-by-step rationale: 1. The Synergy Model emphasizes matching nurse competencies with patient needs. 2. A male nurse may not be culturally appropriate for a Muslim female patient due to religious beliefs. 3. Gender segregation is important in Islamic culture, especially concerning intimate care. 4. Therefore, assigning a new graduate male nurse to care for a Muslim female patient in critical condition is the most inappropriate choice. Summary: - Choice A is incorrect because being a new graduate does not impact cultural competence. - Choice B is incorrect as experience does not necessarily make a nurse the best fit for a specific patient. - Choice D is incorrect as postpartum experience is relevant, but cultural considerations are more critical in this scenario.
Question 6 of 9
As part of nursing management of a critically ill patient, o rders are written to keep the head of the bed elevated at 30 degrees, awaken the patient from se dation each morning to assess readiness to wean from mechanical ventilation, and implement oral care protocols every 4 hours. These interventions are done as a group to reduce thabei rrbi.csokm o/tef svt entilator-associated pneumonia. This group of evidence-based interventions is often referred to using what term?
Correct Answer: A
Rationale: The correct answer is A: Bundle of care. A bundle of care refers to a set of evidence-based interventions that, when implemented together, have been shown to improve patient outcomes. In this scenario, keeping the head of the bed elevated, daily awakening from sedation, and oral care protocols are bundled together to reduce the risk of ventilator-associated pneumonia. This approach is based on the idea that implementing multiple interventions simultaneously is more effective than individual interventions alone. Choices B, C, and D are incorrect because: B: Clinical practice guidelines provide recommendations for healthcare providers based on evidence but do not necessarily involve a group of interventions bundled together. C: Patient safety goals are specific objectives aimed at improving patient safety outcomes, but they do not specifically refer to a group of interventions bundled together. D: Quality improvement initiatives focus on improving processes and outcomes in healthcare settings but do not necessarily involve a group of interventions bundled together for a specific purpose like in this case.
Question 7 of 9
The nurse assesses a patient who is admitted for an overdo se of sedatives. The nurse expects to find which acid-base alteration?
Correct Answer: B
Rationale: The correct answer is B: Hypoventilation and respiratory acidosis. When a patient overdoses on sedatives, it can lead to respiratory depression causing hypoventilation. Hypoventilation results in retention of CO2, leading to respiratory acidosis. This is because the body is not effectively exhaling CO2, causing an increase in carbonic acid levels and a decrease in blood pH. The other choices are incorrect because hyperventilation would lead to respiratory alkalosis (Choice A), hypoventilation does not cause respiratory alkalosis (Choice C), and normal oxygen levels do not indicate the acid-base imbalance caused by sedative overdose (Choice D).
Question 8 of 9
The nurse returns from the cardiac catheterization laboratory with a patient following insertion of a pulmonary artery catheter and assists in transferring th e patient from the stretcher to the bed. Prior to obtaining a cardiac output, which action is m ost important for the nurse to complete?
Correct Answer: B
Rationale: The correct answer is B: Zero reference the transducer system at the phlebostatic axis. This is the most important action before obtaining a cardiac output because zero referencing ensures accurate pressure readings. The phlebostatic axis is the level of the atria when the patient is supine, and zeroing at this point minimizes errors in pressure measurements. Choice A is incorrect because documenting a pulmonary artery catheter occlusion pressure is not the priority at this stage. Choice C is incorrect as inflating the balloon with air should be done after zero referencing. Choice D is incorrect as injecting normal saline into the port is not necessary before zero referencing.
Question 9 of 9
The patient undergoes a cardiac catheterization that requires the use of contrast dyes during the procedure. To detect signs of contrast-induced kidney injury, the nurse should
Correct Answer: B
Rationale: The correct answer is B because evaluating the patient's serum creatinine for up to 72 hours after the procedure is crucial in detecting contrast-induced kidney injury. An increase in serum creatinine levels indicates impaired kidney function due to the contrast dye. This monitoring allows for early detection and intervention to prevent further kidney damage. Choice A is incorrect because a decrease in urine output is a late sign of kidney injury and may not be present in the early stages. Choice C is incorrect as a renal ultrasound is not typically used to detect contrast-induced kidney injury. Choice D is incorrect as postvoid residual volume assessment is not specific to detecting intrarenal injury related to contrast dye use.