While family members are visiting, a patient has a respiratory arrest and is being resuscitated. Which action by the nurse is best?

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Critical Care Nursing Practice Questions Questions

Question 1 of 9

While family members are visiting, a patient has a respiratory arrest and is being resuscitated. Which action by the nurse is best?

Correct Answer: A

Rationale: The correct answer is A because it respects the patient's right to privacy while also acknowledging the family's presence. By asking family members if they wish to remain in the room, the nurse allows them to make an informed decision based on their comfort level. This approach fosters open communication and shows respect for the family's emotions. Choice B is incorrect because abruptly removing family members can increase their distress and feelings of powerlessness. Choice C is incorrect as it places the burden of support solely on a staff member, potentially isolating the family from the situation. Choice D is incorrect as it assumes family members should stay without considering their preferences or emotional well-being.

Question 2 of 9

The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?

Correct Answer: C

Rationale: The correct answer is C: Ptosis on the left eyelid. Ptosis refers to drooping of the eyelid, which is a common condition in older adults. In this scenario, the nurse should document the finding as ptosis on the left eyelid because the client's left upper eyelid is drooping, covering more of the iris than the right eyelid. Explanation: Nystagmus (A) is an involuntary eye movement, not related to eyelid drooping. Exophthalmos (B) is the protrusion of the eyeball and not relevant to this scenario. Astigmatism (D) refers to a refractive error of the eye and does not cause eyelid drooping. Therefore, the correct choice is C as it accurately describes the client's condition.

Question 3 of 9

The patient is getting hemodialysis for the second time when he complains of a headache and nausea and, a little later, of becoming confused. The nurse realizes these are symptoms of

Correct Answer: C

Rationale: The correct answer is C: dialysis disequilibrium syndrome. This occurs when there is a rapid decrease in urea concentration in the blood during hemodialysis, causing fluid shifts and cerebral edema leading to symptoms like headache, nausea, and confusion. Dialyzer membrane incompatibility (A) would present with allergic reactions, not neurological symptoms. A shift in potassium levels (B) may cause muscle weakness or cardiac arrhythmias, but not the described symptoms. Hypothermia (D) would present with low body temperature and shivering, not the neurological symptoms mentioned.

Question 4 of 9

The critical care unit environment is very stressful for patients, families, and staff. What nursing action is directed at reducing environmental stress?

Correct Answer: D

Rationale: The correct answer is D: Maintaining a quiet environment during hours of sleep. This action is directed at reducing environmental stress in the critical care unit because noise and disturbances during sleep can negatively impact patients' rest and recovery. By ensuring a quiet environment, patients can have uninterrupted sleep, which is crucial for healing. Rationale: 1. Constant expert evaluation of patient status (A) may be important but does not directly address environmental stress. 2. Limiting visits to immediate family (B) may hinder patients' emotional support and can be stressful for families. 3. Bathing all patients during hours of sleep (C) may disrupt patients' rest and increase stress levels rather than reduce it.

Question 5 of 9

A nurse has achieved certification in critical care nursing. What is the most important effect that this certification will have on the nurses practice?

Correct Answer: D

Rationale: The correct answer is D: Increased confidence in critical thinking. Achieving certification in critical care nursing validates the nurse's expertise and knowledge in this specialized area, leading to increased confidence in their ability to critically think through complex patient situations. This confidence translates into improved clinical decision-making and patient outcomes. A: Recognition by peers - While recognition by peers is important for professional growth, the primary benefit of certification is enhancing clinical skills. B: Increase in salary and rank - While certification may lead to salary increases in some cases, the most significant impact is on improving clinical skills. C: More flexibility in seeking employment - While certification may enhance employability, the focus is on improving critical thinking skills rather than employment opportunities.

Question 6 of 9

The nurse is caring for a terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be most appropriate?

Correct Answer: D

Rationale: The correct answer is D because the patient is exhibiting Cheyne-Stokes breathing pattern characterized by periods of apnea followed by deep and rapid breathing. The nurse should document this pattern accurately. Option A is incorrect as suctioning is not indicated. Option B may worsen the respiratory pattern. Option C is not specifically related to addressing the breathing pattern.

Question 7 of 9

Which of the following strategies will assist in creating a h ealthy work environment for the critical care nurse? (Select all that apply.)

Correct Answer: B

Rationale: The correct answer is B because implementing a medication safety program designed by pharmacists promotes a safe work environment for critical care nurses by reducing medication errors. Pharmacists are experts in medications and can provide valuable insights to improve safety. A: Celebrating with a pizza party may boost morale but does not directly address work environment factors. C: Modifying staffing ratios may improve patient care but doesn't necessarily address the overall work environment. D: Joint workshops foster collaboration but may not directly impact the work environment's safety and health.

Question 8 of 9

The nurse is assessing the exhaled tidal volume (EV ) in a mechanically ventilated patient. T What is the rationale for this assessment?

Correct Answer: D

Rationale: The correct answer is D: Determine the patient’s work of breathing. Assessing the exhaled tidal volume (EV) in a mechanically ventilated patient helps determine how much effort the patient is exerting to breathe. By monitoring the EV, the nurse can evaluate the patient's respiratory status and adjust ventilator settings if needed. It is crucial to ensure that the patient is not working too hard to breathe, as this can lead to respiratory distress. Incorrect answers: A: Assess for tension pneumothorax - Tension pneumothorax is typically assessed through other means such as physical examination and chest X-ray. B: Assess the level of positive end-expiratory pressure - The level of positive end-expiratory pressure is usually set based on the patient's condition and not solely based on the exhaled tidal volume. C: Compare the tidal volume delivered with the tidal volume prescribed - This comparison is important but does not directly relate to assessing the patient's work of breathing.

Question 9 of 9

The patient’s serum creatinine level is 0.7 mg/dL. The expected BUN level should be

Correct Answer: C

Rationale: The correct answer is C (10 to 20 mg/dL). The normal BUN-to-creatinine ratio is approximately 10:1. With a serum creatinine level of 0.7 mg/dL, the expected BUN level should be around 7 to 14 mg/dL. Therefore, choice C (10 to 20 mg/dL) falls within this expected range. Choices A, B, and D are incorrect as they do not align with the typical BUN-to-creatinine ratio and would indicate abnormal kidney function.

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