Critical Care Nursing NCLEX Questions

Correct Answer: A

Rationale: The correct answer is A: A patient with a red tag. In triage, red tags indicate patients with life-threatening injuries who require immediate attention. The nurse must assess this patient first to provide necessary interventions. Patients with blue tags are considered urgent but stable, black tags are deceased or beyond help, and yellow tags are for delayed treatment. Assessing the red-tagged patient first ensures prompt care for those in critical condition.

Correct Answer: A

Rationale: Step-by-step rationale for why choice A is correct: 1. Involving the family in patient care is crucial for holistic care. 2. Assessing family relationships helps identify support systems and potential conflicts. 3. Understanding family dynamics aids in creating a comprehensive care plan. 4. Family involvement can enhance patient outcomes and satisfaction. Summary of incorrect choices: B. Irrelevant, as the focus is on patient-centered care, not just fulfilling an assessment tool. C. Personal curiosity is not a valid reason for assessing family relationships in healthcare. D. Conducting research on family patterns does not directly impact the immediate care of the patient.

Correct Answer: C

Rationale: The correct response is C: Your pain medication is already at the highest possible dose. This response acknowledges the patient's pain and reassures them that they are already receiving the maximum safe amount of pain medication. By stating this, the nurse is validating the patient's experience and showing empathy. It is important for the nurse to communicate clearly about the medication to manage the patient's expectations. Choice A is incorrect as it dismisses the patient's pain and can come across as insensitive. Choice B may be well-intentioned but does not address the immediate concern of the patient's pain. Choice D is irrelevant to the patient's statement about pain and does not offer any immediate support or reassurance regarding the pain management.

Correct Answer: B

Rationale: The correct answer is B: Disconnect the flush system from the arterial line catheter. This action is necessary to prevent air from entering the patient's bloodstream, which can lead to air embolism. By disconnecting the flush system, the nurse stops the flow of air and ensures patient safety. Checking the inflation volume of the pressurized bag (A) is not the immediate concern in this situation. Zero referencing the transducer system (C) is unrelated to the issue of air entering the arterial line. Reducing the number of stopcocks in the flush system tubing (D) does not address the immediate risk of air embolism.

Correct Answer: C

Rationale: The correct answer is C, the 86-year-old postoperative from colonic resection. This patient is at the greatest risk for delirium due to being elderly, having undergone surgery, and having a history of being from a nursing home. These factors contribute to an increased susceptibility to delirium. A: The 36-year-old with alcohol withdrawal may be at risk for delirium tremens, but the older age of the patient in choice C places them at higher risk. B: The 54-year-old with an elevated creatinine level postoperative is at risk for complications, but age and history of nursing home placement increase the risk for delirium in choice C. D: The 95-year-old with community-acquired pneumonia is at risk for delirium, but the combination of age, surgery, and nursing home history in choice C presents a greater risk.