ATI RN
Critical Care Nursing Questions Questions
Question 1 of 5
Which therapeutic interventions may be withdrawn or withabhirebl.dco mfr/otemst the terminally ill client?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 Pain medications (D) are essential for managing pain and should not be withdrawn unless no longer beneficial or requested by the patient.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 2 of 5
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 3 of 5
The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of paralysis?
Correct Answer: B
Rationale: The correct answer is B: Train-of-four yields two twitches. This assessment indicates a target level of paralysis because a train-of-four ratio of 2 twitches out of 4 suggests a 50% neuromuscular blockade, which is often the goal for patients receiving paralysis for procedures or ventilation. A: A Glasgow Coma Scale score of 3 assesses consciousness, not neuromuscular blockade. C: A Bispectral index of 60 measures depth of anesthesia, not paralysis level. D: CAM-ICU assesses delirium, not neuromuscular blockade.
Question 4 of 5
The nurse is assessing pain levels in a critically ill patient . The nurse recognizes that which patient action as indicatin g the greatest level of pain?
Correct Answer: C
Rationale: Correct Answer: C (Grimacing) Rationale: 1. Grimacing is a universal nonverbal sign of pain. 2. It involves facial muscles, indicating a high level of discomfort. 3. Brow lowering and eyelid closing are subtle signs, less indicative of severe pain. 4. Staring may signify concentration, not necessarily pain. Summary: Grimacing is the correct choice as it directly correlates with pain intensity, unlike the other options which are less specific or relevant indicators of severe pain.
Question 5 of 5
The nurse recognizes that which patient is likely to benefit most from patient-controlled analgesia?
Correct Answer: A
Rationale: The correct answer is A, the 21-year-old with a C4 fracture and quadriplegia. This patient is likely to benefit most from patient-controlled analgesia (PCA) due to the inability to self-administer traditional pain medications. With quadriplegia, the patient may have limited mobility and sensation, making it challenging to communicate pain levels effectively. PCA allows the patient to control their pain relief within preset limits, enhancing autonomy and optimizing pain management. Summary: - Choice B: The 45-year-old with femur fracture and closed head injury may benefit from PCA, but the severity of the head injury could affect their ability to use the device effectively. - Choice C: The 59-year-old postoperative elective bariatric surgery patient can typically manage pain with traditional methods postoperatively. - Choice D: The 70-year-old postoperative cardiac surgery patient with mild dementia may have the cognitive ability to use PCA but could potentially benefit more from other pain management strategies due