Critical Care Nursing Questions

Correct Answer: D

Rationale: The correct answer is D: Administer the medication. Atenolol is a beta-blocker used to reduce heart rate and blood pressure. In this scenario, the client's apical pulse of 65 beats per minute is within the normal range for a client taking atenolol after a myocardial infarction. Therefore, the nurse should proceed with administering the medication as prescribed to help maintain the client's heart rate and blood pressure within the therapeutic range. A: Measuring the blood pressure is important but not the immediate next step as the client's heart rate is within the normal range. B: Reassessing the apical pulse is unnecessary since it is already within the normal range for a client on atenolol. C: Notifying the healthcare provider is not indicated as there are no signs of concern with the client's heart rate at 65 bpm.

Correct Answer: D

Rationale: The correct answer is D: Increased jugular venous distention. In a patient with a subarachnoid hemorrhage and on mechanical ventilation, increased jugular venous distention can indicate increased intracranial pressure, which can be life-threatening. The nurse should notify the healthcare provider immediately as it may require urgent intervention to prevent further neurological deterioration. A: Oxygen saturation of 93% is within the acceptable range for a patient on mechanical ventilation and may not require immediate notification. B: Respirations of 20 breaths/minute are within normal limits for a ventilated patient and do not necessarily indicate a critical condition. C: Green nasogastric tube drainage may indicate the presence of bile and could be related to gastrointestinal issues, but it does not pose an immediate threat to the patient's neurological status.

Correct Answer: A

Rationale: The correct answer is A: Encourage the family to participate in patient care tasks. This intervention helps to alleviate stress by involving the family in care, promoting a sense of control and empowerment. It also fosters a collaborative relationship between the family and healthcare team. The other choices are incorrect because B only focuses on asking questions but doesn't actively involve the family in care. C may add pressure on the selected representative and exclude others. D limits family involvement and may increase stress by restricting visitation.

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.

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.