Critical Care Nursing NCLEX Questions

Correct Answer: B

Rationale: The correct answer is B: Assist with the intubation of the patient. In this scenario, the patient is unconscious and has ingested a potentially harmful substance. Intubation is the first priority to maintain the patient's airway and ensure adequate oxygenation. This step is crucial in preventing aspiration of gastric contents and securing the patient's respiratory status. Inserting a large-bore orogastric tube (choice A) is not the priority as airway management takes precedence. Preparing a syringe with saline (choice C) is unnecessary at this stage. Giving the first dose of activated charcoal (choice D) should only be done after securing the airway to prevent aspiration.

Correct Answer: A

Rationale: The correct answer is A: Agitation. In hyperactive delirium, patients often exhibit restlessness, agitation, and hyperactivity. This behavior is a key characteristic indicating hyperactive delirium. Apathy (B), biting (C), and hitting (D) are not typically associated with hyperactive delirium. Apathy may be seen in hypoactive delirium, while biting and hitting are not specific indicators of delirium subtypes. Therefore, the correct choice is A as it aligns with the typical presentation of hyperactive delirium.

Correct Answer: A

Rationale: The correct answer is A: high Fowler's position. This position promotes optimal lung expansion by allowing the chest to expand fully, improving oxygenation. It also helps reduce the work of breathing. Side lying with the head of the bed elevated (B) may not provide the same level of lung expansion. Sitting in a chair (C) may not be suitable for a patient in acute respiratory failure as it may not provide adequate support for breathing. Supine with the bed flat (D) can worsen respiratory distress by limiting lung expansion.

Correct Answer: C

Rationale: Rationale: - Improved collaboration enhances job satisfaction and reduces burnout, leading to increased staff retention. - Higher staff retention promotes continuity of care, improves team dynamics, and enhances patient outcomes. Summary: - A: Not directly related to collaboration, more about performance evaluation. - B: Manners may improve, but not the most important effect of collaboration. - D: Collaboration involves open communication, so less discussion in front of patients is not a positive outcome.

Correct Answer: B

Rationale: The correct answer is B: Obtain a Glasgow Coma Scale score. During the primary survey, assessing the patient's level of consciousness is crucial as it helps determine the severity of the injury and guides further management. The Glasgow Coma Scale is a standardized tool used to assess the level of consciousness based on eye opening, verbal response, and motor response. It provides valuable information about the patient's neurological status. A: Obtaining a complete set of vital signs is important but assessing the level of consciousness takes priority in this scenario. C: Asking about chronic medical conditions is important but not as critical as assessing the patient's level of consciousness during the primary survey. D: Attaching a cardiac electrocardiogram monitor is not necessary during the primary survey unless there are specific indications of cardiac issues, which are not evident in this case. In summary, obtaining a Glasgow Coma Scale score is essential for assessing the patient's level of consciousness and determining the severity of the injury during the primary survey.