Critical Care Nursing Exam Questions

Correct Answer: C

Rationale: The correct answer is C: Auscultate breath sounds. After a near-drowning incident, the main concern is potential respiratory complications such as aspiration pneumonia or pulmonary edema. Auscultating breath sounds will help the nurse assess for any signs of respiratory distress or complications. This assessment is crucial for early detection and intervention. A: Auscultating heart sounds is important but not as crucial as assessing breath sounds in this scenario. B: Palpating peripheral pulses is important for circulation assessment but does not address the immediate concern of respiratory complications. D: Checking pupil reaction to light is more relevant for neurological assessment and not as critical as assessing breathing in this situation.

Correct Answer: B

Rationale: The correct answer is B because volunteering to serve on a disaster response planning committee demonstrates awareness of current events affecting critical care nursing. By actively participating in planning for potential disasters, the nurse shows a proactive approach to staying informed and prepared for emergencies. This behavior indicates a commitment to staying up-to-date with the evolving landscape of critical care nursing. Choices A, C, and D are incorrect because: A: Participating in recruitment efforts may be important but does not directly demonstrate awareness of current events affecting critical care nursing. C: Adhering to basic nursing program content is necessary but does not show active engagement with current events in critical care nursing. D: Attending hospital-mandated in-services is valuable, but without seeking additional education or involvement in current events, it does not illustrate awareness of the changing critical care nursing environment.

Correct Answer: D

Rationale: The correct action is D: Manually ventilate the patient with 100% oxygen. This is crucial to ensure adequate oxygenation and prevent hypoxia. Holding the ET tube can lead to extubation and airway compromise. Activating the rapid response team (A) may delay immediate intervention. Providing reassurance (B) is important but not the priority in this situation. Calling the health care provider (C) to reinsert the tube would also lead to a delay in providing essential respiratory support.

Correct Answer: C

Rationale: First, the nurse should assess the patient's lungs to rule out any potential respiratory issues causing fluid retention. This is crucial as the patient has signs of fluid imbalance with decreased output and increased weight. Assessing the lungs can help identify conditions like heart failure or pneumonia that may contribute to these changes. Drawing a trough level (choice A) is not a priority as it doesn't address the immediate concern of fluid imbalance. Placing the patient on fluid restriction (choice B) should only be done after identifying the cause of the imbalance. Inserting an indwelling catheter (choice D) is not necessary at this point as the issue is related to fluid balance, not urinary elimination.

Correct Answer: D

Rationale: The correct answer is D: Titrate to a predefined endpoint using a standard sedation scale. This approach ensures individualized dosing based on the patient's response, minimizing the risk of over-sedation or under-treatment. It allows for careful monitoring and adjustment of dosage to achieve the desired level of sedation while avoiding adverse effects. A: Administering medication around the clock may lead to unnecessary sedation and increased risk of side effects. B: Administering medications through a feeding tube is not recommended for benzodiazepines as it may affect absorption and increase the risk of complications. C: Giving the highest allowable dose without considering individual response can result in excessive sedation and adverse effects.