Critical Care Nursing NCLEX Questions

Correct Answer: B

Rationale: The correct answer is B because developing a standardized reporting form for family information that is incorporated into the patient's medical record ensures consistency and accuracy in sharing vital details about family structure and dynamics from shift to shift. This method allows all healthcare providers to access the information easily and update it as needed, promoting continuity of care and comprehensive understanding of the family's needs. Choices A, C, and D are incorrect because: A: Creating an informal family information sheet may lead to inconsistencies in the information shared among healthcare providers and may not be updated regularly. C: Requiring only the charge nurse to have detailed information may result in information silos and lack of accessibility for all team members. D: Discussing family dynamics as part of the change-of-shift report may lead to important details being missed or forgotten, compromising the quality of care provided.

Correct Answer: A

Rationale: The correct answer is A because assessing the patient and family's developmental stages and needs is crucial in understanding their current situation and determining the appropriate care plan. By assessing developmental stages, the nurse can tailor interventions to meet the family's specific needs. This assessment also helps in identifying potential challenges or areas requiring support. Choice B is incorrect as it focuses solely on the physical environment and does not address the family's developmental stages and needs. Choice C is incorrect as it emphasizes identifying family members without considering the importance of understanding their developmental stages and needs in providing family-centered care. Choice D is incorrect as it concentrates on family dynamics without directly addressing the crucial aspect of assessing developmental stages and needs for effective family-centered care.

Correct Answer: C

Rationale: The correct answer is C: Considers factors related to safe patient care. The scenario involves the nurse discussing the patient's living will with the physician, which is essential for ensuring safe patient care by following the patient's preferences. This aligns with the AACN standard of considering factors related to safe patient care, as the nurse is actively involving all relevant parties in decision-making to provide care that is in line with the patient's wishes. Explanation of why other choices are incorrect: A: Acquires and maintains current knowledge of practice - While important, this choice does not directly relate to the scenario where the focus is on safe patient care through communication and collaboration. B: Acts ethically on behalf of the patient and family - While ethics are important, the scenario is more about following the patient's wishes as outlined in the living will rather than making ethical decisions. D: Uses clinical inquiry and integrates research findings in practice - While valuable in nursing practice, this choice does not directly apply to the scenario where

Correct Answer: A

Rationale: The correct answer is A because it addresses the husband's concern directly by assuring him that every measure will be taken to provide the best care for his wife. This response shows empathy and provides reassurance, which is crucial in such a stressful situation. It helps to alleviate the husband's anxiety and fear by emphasizing the hospital's commitment to his wife's well-being. Explanation for why the other choices are incorrect: B: This response does not address the husband's immediate concern about his wife's well-being and may come across as dismissive. C: Offering a place to relax does not address the husband's specific question and does not provide the information he is seeking. D: Discussing health insurance is not appropriate at this moment of crisis and does not address the husband's fears about his wife's condition.

Correct Answer: D

Rationale: The correct answer is D: Instill 5 mL of sterile saline into the ET before suctioning. This intervention helps to loosen and mobilize the thick secretions, making them easier to remove during suctioning. It is important to moisten the secretions to prevent mucosal damage and trauma during suctioning. A: Increasing suctioning frequency can lead to mucosal damage and increased risk of infection. B: Repositioning helps with ventilation and preventing pressure injuries, but it does not directly address the thick secretions. C: Adding water to enteral feedings will not directly address the thick secretions in the ET. In summary, instilling sterile saline into the ET before suctioning is the most effective intervention as it helps to loosen and mobilize thick secretions, making suctioning more effective and reducing the risk of mucosal damage.