ATI RN
Critical Care Nursing Cardiac Questions Questions
Question 1 of 5
An unresponsive 79-year-old is admitted to the emergency department (ED) during a summer heat wave. The patient�s core temperature is 105.4�F (40.8�C), blood pressure (BP) 88/50, and pulse 112. The nurse initially will plan to:
Correct Answer: A
Rationale: The correct answer is A: Apply wet sheets and a fan to the patient. This is the initial treatment for hyperthermia to aid in lowering the body temperature. Wet sheets help in evaporative cooling, while a fan enhances heat loss through convection. This approach is crucial in managing heat-related illnesses quickly. Choices B, C, and D are incorrect as they do not directly address the urgent need to reduce the patient's elevated core temperature. Providing O2, IV fluids, or acetaminophen can be considered later in the management, but the priority is to rapidly lower the body temperature in a hyperthermic patient to prevent further complications.
Question 2 of 5
The nurse is managing a donor patient six hours prior to th e scheduled harvesting of the patient�s organs. Which assessment finding requires imme diate action by the nurse?
Correct Answer: B
Rationale: The correct answer is B. The patient's pH of 7.30 indicates acidosis, PaCO2 of 38 mm Hg is low, and HCO3 of 16 mEq/L is also low, suggesting metabolic acidosis. This finding requires immediate action as untreated acidosis can lead to serious complications. Choice A (morning serum blood glucose of 128 mg/dL) is within normal range and does not require immediate action. Choice C (pulmonary artery temperature of 97.8�F) is a normal temperature and does not require immediate action. Choice D (central venous pressure of 8 mm Hg) is within normal range and does not require immediate action.
Question 3 of 5
A new nurse has recently joined the ICU from a different hospital, which had a much stricter policy regarding visiting hours. She expresses concern about the impact of open visiting hours on patient well-being. Which of the following would be the best explanation for the purpose of open visiting hours? Select all that apply.
Correct Answer: B
Rationale: The correct answer is B: To strengthen the relationship between the family and health care provider. Rationale: 1. Open visiting hours encourage family involvement in care, fostering a partnership between healthcare providers and families. 2. Family support can positively impact patient outcomes and satisfaction. 3. It allows families to be updated on the patient's condition and involved in decision-making. 4. Strengthening the relationship can lead to better communication and trust between all parties. Summary of Incorrect Choices: A: Open visiting hours may disrupt rest and quiet, but the primary purpose is not to provide rest. C: Open visiting hours do not aim to control the number of visitors but rather encourage family involvement. D: While open visiting hours may not provide an entirely undisturbed environment, the focus is on improving family-provider relationships.
Question 4 of 5
The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP). Which action indicates that the new RN is safe?
Correct Answer: B
Rationale: The correct answer is B: The RN uses a closed-suction technique to suction the patient. This is the safe action because closed-suction technique minimizes the risk of ventilator-associated infections by maintaining a closed system during suctioning, reducing the exposure to pathogens. Closed-suction systems also help maintain lung compliance and oxygenation levels during the suctioning process. Rationale: Option A is incorrect because suctioning every 1 to 2 hours may be too frequent and can lead to hypoxia and mucosal damage. Option C is incorrect as taping the connection between the ventilator tubing and ET can interfere with the proper functioning of the ventilator and increase the risk of disconnection. Option D is incorrect because changing ventilator circuit tubing routinely every 48 hours is not evidence-based practice and can increase the risk of contamination and unnecessary costs.
Question 5 of 5
The primary care provider orders the following mechanica l ventilation settings for a patient who weighs 75 kg and whose spontaneous respiratory rate is 22 breaths/min. What arterial blood gas abnormality may occur if the patient continues taob ibrbe.c otamc/thesyt pneic at these ventilator settings? Settings: Tidal volume: 600 mL (8 mL per kg) FiO 2: 0.5 Respiratory rate: 14 breaths/min Mode assist/control Positive end-expiratory pressure: 10 cm H O
Correct Answer: C
Rationale: The correct answer is C: Respiratory acidosis may occur if the patient continues at these ventilator settings. Respiratory acidosis happens when the lungs cannot remove enough of the carbon dioxide (CO2) produced by the body. In this case, the low respiratory rate of 14 breaths/min may not be sufficient to adequately remove CO2, leading to its accumulation in the blood. This results in a decrease in blood pH, causing respiratory acidosis. Summary of other choices: A: Metabolic acidosis - Not the correct answer as the ventilator settings are more likely to affect the respiratory system rather than the metabolic system. B: Metabolic alkalosis - Not the correct answer as the ventilator settings are not related to causing an increase in blood pH, which is characteristic of metabolic alkalosis. D: Respiratory alkalosis - Not the correct answer as the low respiratory rate would not lead to excessive elimination of CO2, causing alkalosis.
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