Critical Care Nursing NCLEX Questions

Correct Answer: C

Rationale: Rationale: 1. Intermittent Mandatory Ventilation (IMV) allows the patient to breathe spontaneously between the preset mechanical breaths. 2. It provides a set number of breaths per minute while allowing the patient to initiate additional breaths at their own tidal volume. 3. IMV is a partial ventilatory support mode, providing a balance between controlled and spontaneous breathing. 4. Assist/Control Ventilation (A) provides full support with every breath initiated by the patient or the ventilator. 5. Controlled Ventilation (B) does not allow for spontaneous breaths by the patient. 6. Positive End-Expiratory Pressure (D) is a separate mode focusing on maintaining positive pressure at the end of expiration, not providing breaths.

Correct Answer: D

Rationale: The correct answer is D. The first step in endotracheal intubation is to insert the endotracheal tube with a laryngoscope and blade to visualize the vocal cords and guide the tube into the trachea. This ensures proper placement of the tube for effective ventilation. Assessing the balloon symmetry (Choice A) and lung fields (Choice B) would come after the tube is successfully inserted. Inflating the balloon of the endotracheal tube (Choice C) should be the last step to secure the tube in place.

Correct Answer: C

Rationale: Rationale: 1. Intermittent Mandatory Ventilation (IMV) allows the patient to breathe spontaneously between the preset mechanical breaths. 2. It provides a set number of breaths per minute while allowing the patient to initiate additional breaths at their own tidal volume. 3. IMV is a partial ventilatory support mode, providing a balance between controlled and spontaneous breathing. 4. Assist/Control Ventilation (A) provides full support with every breath initiated by the patient or the ventilator. 5. Controlled Ventilation (B) does not allow for spontaneous breaths by the patient. 6. Positive End-Expiratory Pressure (D) is a separate mode focusing on maintaining positive pressure at the end of expiration, not providing breaths.

Correct Answer: A

Rationale: The correct answer is A: Thirty-degree elevation of the head of the bed. This is the priority nursing intervention for a mechanically ventilated patient following bilateral lung transplantation because it helps optimize ventilation-perfusion matching, reduces the risk of aspiration, and improves oxygenation. Elevating the head of the bed also decreases the risk of ventilator-associated pneumonia. B: Endotracheal suctioning as needed is important but not the priority intervention in this case. C: Frequent side to side repositioning is important for preventing pressure ulcers but is not the priority for a ventilated patient post-lung transplant. D: Sequential compression stockings are used for preventing deep vein thrombosis, which is important but not the priority in this scenario.

Correct Answer: B

Rationale: The correct answer is B because withdrawal is a common psychological response in the dying process. The nurse should explain to the son that his mother's lack of response may be her way of preparing to leave life. This response validates the son's concerns while providing reassurance. Choice A is incorrect because cutting back visits may not address the underlying issue of the mother's withdrawal. Choice C is incorrect because stimulating the mother may not be beneficial or appropriate in this situation. Choice D is incorrect because not all patients experience a lack of awareness at the end of life, and assuming so may not be helpful in this context.