Critical Care Nursing Questions and Answers PDF

Questions 81

ATI RN

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Critical Care Nursing Questions and Answers PDF Questions

Question 1 of 5

A patient who is undergoing withdrawal of mechanical ventilation appears anxious and agitated. The patient is on a continuous morphine infusion and has an additional order for lorazepam 1 to 2 mg IV as needed (prn). The patient has received no lorazepam during this course of illness. What is the most appropriate nursing intearbvirbe.ncotmio/tnes tt o control agitation?

Correct Answer: B

Rationale: Step-by-step rationale for why choice B is correct: 1. Midazolam is a benzodiazepine used for sedation and anxiolysis. 2. It acts quickly and has a short duration of action, suitable for acute agitation. 3. Lorazepam (also a benzodiazepine) is in the same drug class, ensuring compatibility. 4. Lorazepam is specifically ordered for this patient, indicating its appropriateness. 5. Administering midazolam addresses the patient's agitation efficiently and safely. Summary of why other choices are incorrect: A: Fentanyl is an opioid analgesic, not ideal for managing agitation. C: Increasing morphine infusion can exacerbate sedation or respiratory depression. D: Paralytic agents are used for neuromuscular blockade, not agitation control.

Question 2 of 5

The patient is in the critical care unit and will receive dialysis this morning. The nurse will (Select all that apply.)

Correct Answer: A

Rationale: The correct answer is A because evaluating morning lab results is crucial to monitor the patient's condition before dialysis. Abnormal results may impact the dialysis treatment plan. Option B is incorrect as administering antihypertensive medications is not directly related to dialysis. Option C is incorrect as assessing the dialysis access site is the responsibility of the dialysis team. Option D is incorrect as weighing the patient is not typically done immediately before dialysis.

Question 3 of 5

A patient has just been admitted to the ICU after being in a severe auto accident and losing one of her legs. Her husband has his hand over his heart and complains of a rapid heart rate. The nurse recognizes his condition as a sign of which stage of the general adaptation syndrome to stress?

Correct Answer: A

Rationale: The correct answer is A: Alarm stage. The husband's rapid heart rate indicates the initial alarm reaction to stress, characterized by physiological arousal. This stage involves the body's fight-or-flight response to a stressor. In this scenario, the husband is experiencing the physiological effects of the stressful situation, such as the auto accident and loss of a limb. The other choices are incorrect because: B: Exhaustion stage occurs if stress continues without relief, leading to depletion of resources and increased vulnerability to illness. C: Resistance stage is the body's attempt to adapt and cope with the stressor after the initial alarm reaction. D: Adaptation stage is not a recognized stage in the general adaptation syndrome model.

Question 4 of 5

When fluid is present in the alveoli what is the result?

Correct Answer: A

Rationale: The correct answer is A: Alveoli collapse and atelectasis occurs. When fluid is present in the alveoli, it impairs the surface tension necessary for the alveoli to remain open, leading to collapse and atelectasis. This prevents proper gas exchange, resulting in hypoxemia. Choice B is incorrect because impaired gas diffusion typically occurs with conditions affecting the alveolar-capillary membrane, not fluid in the alveoli. Choice C is incorrect as hypoventilation refers to decreased ventilation, not specifically related to fluid in the alveoli. Choice D is incorrect as fluid in the alveoli is not a direct indicator of heart failure.

Question 5 of 5

The nurse is assessing the patient�s pain using the Critical Care Pain Observation Tool (CPOT). Which of the following assessments would indicate the greatest likelihood of pain and need for nursing intervention?

Correct Answer: B

Rationale: The correct answer is B: Fighting the ventilator. This behavior indicates the patient is experiencing discomfort and struggling against the ventilator, suggesting a high likelihood of pain. The CPOT assesses pain through behaviors like grimacing, vocalization, and muscle tension, which are all present when a patient is fighting the ventilator. Absence of vocal sounds (Choice A) does not necessarily indicate pain as some patients may be silent even when in pain. Moving legs in bed (Choice C) could be due to restlessness rather than pain. Relaxed muscles in upper extremities (Choice D) do not reflect pain as the CPOT focuses on behaviors indicating discomfort.

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