Critical Care Nursing Questions

Correct Answer: A

Rationale: The correct answer is A: Assess the patient's current vital signs. The nurse's first action should be to gather objective data to assess the patient's condition and determine the urgency of the situation. Vital signs, including temperature, heart rate, blood pressure, and respiratory rate, provide crucial information for the initial assessment. This will help the nurse identify any signs of sepsis, shock, or other serious conditions that require immediate intervention. The other choices are incorrect because: B: Giving acetaminophen without assessing the patient's vital signs and determining the cause of the symptoms could mask important clinical information and delay appropriate treatment. C: While obtaining a urine sample may be necessary later to rule out a urinary tract infection, it is not the most immediate priority in this case. D: Delaying the patient's assessment and care based on estimated wait times is not appropriate when the patient presents with potentially serious symptoms. Immediate evaluation is required in this scenario.

Correct Answer: C

Rationale: Step-by-step rationale: 1. The Synergy Model emphasizes matching nurse competencies with patient needs. 2. A male nurse may not be culturally appropriate for a Muslim female patient due to religious beliefs. 3. Gender segregation is important in Islamic culture, especially concerning intimate care. 4. Therefore, assigning a new graduate male nurse to care for a Muslim female patient in critical condition is the most inappropriate choice. Summary: - Choice A is incorrect because being a new graduate does not impact cultural competence. - Choice B is incorrect as experience does not necessarily make a nurse the best fit for a specific patient. - Choice D is incorrect as postpartum experience is relevant, but cultural considerations are more critical in this scenario.

Correct Answer: B

Rationale: To calculate the IV fluids for a 19.5 kg child: 1. For the first 10 kg: 1000 mL 2. For the weight between 10-20 kg: (19.5 kg - 10 kg) * 50 mL/kg = 475 mL Total IV fluids = 1000 mL + 475 mL = 1475 mL To convert to mL per hour: 1475 mL / 24 hours = ~61 mL/hr Therefore, the correct answer is B (61 mL/hr). Incorrect Choices: A (24 mL/hr): Incorrect, as it doesn't consider the additional fluids for the weight between 10-20 kg. C (73 mL/hr) and D (58 mL/hr): Incorrect, as these values are not obtained from the correct calculation based on the given formula.

Correct Answer: D

Rationale: The correct answer is D because inflating the cuff until a slight leak is heard only at peak inflation ensures it is adequately sealed but not overinflated, preventing complications like tracheal injury or pressure necrosis. Choice A lacks specificity and can lead to overinflation. Choice B may result in overinflation as the firmness of the balloon is subjective. Choice C relies on a specific pressure reading, which may vary based on factors like tube size and patient anatomy, potentially leading to under- or overinflation.

Correct Answer: D

Rationale: The correct answer is D because it accurately states that withholding "extraordinary" resuscitation is legal and should be based on specified criteria in advance directives and physician orders. This is in line with medical ethics and patient autonomy. A is incorrect because family presence during resuscitation can be beneficial for emotional support and decision-making. B is incorrect as it is still necessary for a physician to document "do not resuscitate" orders even with a healthcare surrogate. C is incorrect as "slow codes" are not ethical and go against the principle of beneficence.