Critical Care Nursing Questions

Correct Answer: A

Rationale: The correct answer is A: Bundle of care. A bundle of care refers to a set of evidence-based interventions that, when implemented together, have been shown to improve patient outcomes. In this scenario, keeping the head of the bed elevated, daily awakening from sedation, and oral care protocols are bundled together to reduce the risk of ventilator-associated pneumonia. This approach is based on the idea that implementing multiple interventions simultaneously is more effective than individual interventions alone. Choices B, C, and D are incorrect because: B: Clinical practice guidelines provide recommendations for healthcare providers based on evidence but do not necessarily involve a group of interventions bundled together. C: Patient safety goals are specific objectives aimed at improving patient safety outcomes, but they do not specifically refer to a group of interventions bundled together. D: Quality improvement initiatives focus on improving processes and outcomes in healthcare settings but do not necessarily involve a group of interventions bundled together for a specific purpose like in this case.

Correct Answer: B

Rationale: The correct answer is B: Explaining all procedures in easy-to-understand terms. This intervention is appropriate as it helps reduce the patient's anxiety by providing clear information about what to expect during their stay in the critical care unit. This promotes a sense of control and understanding, which can positively impact the patient's coping mechanisms. A: Allowing unrestricted visiting by several family members at one time may overwhelm the patient and interfere with their rest and recovery. C: Providing back massage and mouth care may be beneficial but may not directly address the patient's need for information and understanding. D: Turning down the alarm volume on the cardiac monitor may provide a more comfortable environment but does not address the patient's emotional and psychological needs related to coping with admission to the critical care unit.

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: B

Rationale: The correct answer is B: A deep vein thrombosis from lower extremities. Deep vein thrombosis (DVT) is the most common cause of a pulmonary embolus as a blood clot can dislodge from the veins, travel to the lungs, and block blood flow. An amniotic fluid embolus (Choice A) occurs during childbirth and is rare as a cause of pulmonary embolism. A fat embolus (Choice C) typically occurs after a long bone fracture and is more likely to cause issues in the lungs. Vegetation from an infected central venous catheter (Choice D) can cause septic pulmonary embolism, but it is not as common as DVT.

Correct Answer: A

Rationale: The correct answer is A: Cyclical exacerbation of one another. Pain and anxiety can intensify each other in a cyclical manner. Pain can trigger anxiety, making the pain feel worse, and anxiety can heighten pain perception. This relationship is well-documented in research and clinical practice. Choice B is incorrect because although both pain and anxiety benefit from thorough nursing assessment, it is not a factor common to both conditions. Choice C is incorrect as both pain and anxiety can be influenced by real and perceived phenomena, not solely real phenomena. Choice D is incorrect because while previous experiences can impact pain and anxiety perception, it is not a factor common to both conditions.