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: B

Rationale: Step 1: Start with Background - statement B provides relevant background information about the patient's current condition and why there is a need for communication. Step 2: Move on to Situation - statement D sets the current situation where the nurse expresses concern about the patient's symptom. Step 3: Next is Assessment - statement C details the nurse's assessment findings, highlighting the critical aspects of the patient's condition. Step 4: End with Recommendation - statement A suggests the necessary action to be taken based on the assessment findings. This order ensures a clear and structured communication process. Summary: - Choice A is incorrect as the recommendation should come after providing background, situation, and assessment. - Choice C is incorrect as assessment details should precede the patient's critical condition. - Choice D is incorrect as the situation should be explained before expressing concern.

Correct Answer: B

Rationale: The correct answer is B: She is in the exhaustion stage of the general adaptation syndrome to stress. Rationale: 1. In the exhaustion stage, the body's resources are depleted due to prolonged stress, leading to fatigue and reduced ability to cope. 2. The elderly woman is likely experiencing high levels of stress due to her granddaughter's critical condition. 3. Managing toddlers while dealing with the emotional distress of a loved one in the ICU can be overwhelming, causing exhaustion. 4. This explanation aligns with the symptoms of fatigue and difficulty managing the children observed by the nurse. Summary: A: Incorrect. Senility is a cognitive condition unrelated to the stress of the situation. C: Incorrect. Assuming a caregiver role can be stressful, but it does not explain the observed exhaustion. D: Incorrect. Macular degeneration affects vision, not the ability to manage stress and children.

Correct Answer: B

Rationale: The correct answer is B: Appropriate staffing. In this scenario, the nurse is conflicted because she is the only nurse available to tend to both critical patients. Appropriate staffing ensures that there are enough healthcare professionals to provide timely and effective care to patients in need. In this situation, the lack of adequate staffing is evident as the nurse is overwhelmed and unable to give proper attention to both patients simultaneously. Effective decision making (choice A) can be hindered by inadequate staffing but is not the primary issue here. Authentic leadership (choice C) and meaningful recognition (choice D) are important components of a healthy work environment but are not directly related to the lack of staffing in this scenario.

Correct Answer: C

Rationale: Step 1: The objective is for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Step 2: Choice C states that the client drinks 240 mL of fluid five times during the shift, totaling 1200 mL (240 mL x 5) which exceeds the required amount. Step 3: Therefore, choice C is the correct answer as it demonstrates successful achievement of the objective by ensuring the client has ingested enough fluid within the specified time frame. Step 4: Choices A, B, and D are incorrect as they do not directly address the specific objective of fluid intake set for the client. Option A focuses on intake and output, option B relates to abdominal comfort, and option D is about voiding, none of which directly address the specified objective of fluid ingestion.