Critical Care Nursing Practice Questions

Correct Answer: B

Rationale: The correct answer is B: Partly compensated respiratory acidosis, normal oxygen. The pH of 7.31 indicates acidosis, the PaCO2 of 48 mm Hg shows respiratory acidosis, and the bicarbonate level of 22 mEq/L is slightly elevated, indicating the kidneys are compensating. The PaO2 of 115 mm Hg and oxygen saturation of 99% are normal, ruling out hypoxemia. Therefore, the patient is experiencing partly compensated respiratory acidosis. A: Normal arterial blood gas levels with a high oxygen level - Incorrect. The pH is low, indicating acidosis, which is not normal. C: Uncompensated metabolic acidosis with high oxygen level - Incorrect. Metabolic acidosis would have a primary issue with bicarbonate levels, which is not the case here. D: Uncompensated respiratory acidosis; hyperoxygenated - Incorrect. The oxygen levels are normal, ruling out hyperoxygenation.

Correct Answer: C

Rationale: The correct answer is C because notifying the organ procurement organization (OPO) once the patient has been pronounced brain dead is a requirement to sustain CMS Conditions of Participation. This step ensures that the proper protocols are followed for organ donation. Choice A is incorrect because notifying the OPO of impending death is not a requirement for sustaining CMS Conditions of Participation. Choice B is incorrect because obtaining informed consent for organ donation is not directly related to meeting the requirements of CMS Conditions of Participation. Choice D is incorrect because while evaluating the patient's suitability for organ donation is important, it is not a specific requirement under CMS Conditions of Participation.

Correct Answer: B

Rationale: The correct answer is B: Apply pressure to the insertion site for 5 minutes. This is the priority nursing action because it helps prevent bleeding and hematoma formation after removing the arterial line. Applying pressure for 5 minutes allows for adequate hemostasis. A: Applying an air occlusion dressing to the insertion site is not the priority action. It does not address the immediate need to control bleeding. C: Elevating the affected limb on pillows for 24 hours is not necessary and does not address the immediate need for hemostasis. D: Keeping the patient's wrist in a neutral position is not the priority action when discontinuing an arterial line. It does not address the need for hemostasis and preventing bleeding.

Correct Answer: D

Rationale: The correct answer is D: Determine the patient�s work of breathing. Assessing the exhaled tidal volume (EV) in a mechanically ventilated patient helps determine how much effort the patient is exerting to breathe. By monitoring the EV, the nurse can evaluate the patient's respiratory status and adjust ventilator settings if needed. It is crucial to ensure that the patient is not working too hard to breathe, as this can lead to respiratory distress. Incorrect answers: A: Assess for tension pneumothorax - Tension pneumothorax is typically assessed through other means such as physical examination and chest X-ray. B: Assess the level of positive end-expiratory pressure - The level of positive end-expiratory pressure is usually set based on the patient's condition and not solely based on the exhaled tidal volume. C: Compare the tidal volume delivered with the tidal volume prescribed - This comparison is important but does not directly relate to assessing the patient's work of breathing.

Correct Answer: D

Rationale: The correct answer is D because the patient is exhibiting Cheyne-Stokes breathing pattern characterized by periods of apnea followed by deep and rapid breathing. The nurse should document this pattern accurately. Option A is incorrect as suctioning is not indicated. Option B may worsen the respiratory pattern. Option C is not specifically related to addressing the breathing pattern.