Critical Care Nursing Questions and Answers PDF

Correct Answer: B

Rationale: The correct answer is B: Fighting the ventilator. This behavior indicates the patient is experiencing discomfort and struggling against the ventilator, suggesting a high likelihood of pain. The CPOT assesses pain through behaviors like grimacing, vocalization, and muscle tension, which are all present when a patient is fighting the ventilator. Absence of vocal sounds (Choice A) does not necessarily indicate pain as some patients may be silent even when in pain. Moving legs in bed (Choice C) could be due to restlessness rather than pain. Relaxed muscles in upper extremities (Choice D) do not reflect pain as the CPOT focuses on behaviors indicating discomfort.

Correct Answer: D

Rationale: The correct answer is D: Administer furosemide 20 mg intravenously. In this scenario, the patient is hypotensive with a low cardiac output, low CVP, and low PAOP, indicating cardiogenic shock. Administering furosemide, a diuretic, can worsen the patient's condition by further decreasing preload. This can lead to a decrease in cardiac output and exacerbate the shock state. The other options are more appropriate: A: Titrate supplemental oxygen to achieve a SpO > 94% - Correct, as improving oxygenation is essential in cardiogenic shock. B: Infuse 500 mL 0.9% normal saline over 1 hour - Correct, as fluid resuscitation may be necessary to improve perfusion. C: Obtain arterial blood gas and serum electrolytes - Correct, as these tests provide valuable information about the patient's oxygenation and electrolyte balance.

Correct Answer: B

Rationale: The correct answer is B because informed consent requires the patient to have knowledge and competence to make a decision. This involves understanding the risks, benefits, and alternatives of the proposed treatment. Choice A is incorrect as it pertains to a physical ability unrelated to decision-making. Choice C is incorrect as consent must be verbal or written, not just nodding. Choice D is incorrect as consent can be obtained in various ways, not specifically through reading and writing in English.

Correct Answer: D

Rationale: The correct answer is D: Pulmonary artery wedge pressure (PAWP). This is crucial in monitoring a patient with a large anterior wall myocardial infarction as it provides information on left ventricular function and fluid status. A high PAWP may indicate left ventricular failure or fluid overload, requiring immediate intervention. A: Central venous pressure (CVP) is not as specific for assessing left ventricular function and may not provide accurate information in this scenario. B: Systemic vascular resistance (SVR) is important in assessing systemic blood flow, but it may not directly indicate left ventricular function in this case. C: Pulmonary vascular resistance (PVR) is more relevant in conditions affecting the pulmonary circulation and may not be as immediately informative in assessing left ventricular function in this context.

Correct Answer: A

Rationale: The correct answer is A because assessing the structure of the family (who comprises the family) is not the last step in family assessment. The rationale is that understanding the family structure is essential at the beginning of the assessment process to identify key relationships and support systems. Assessing interaction among family members helps to understand dynamics and relationships within the family. Assessing communication is crucial to identify roles and patterns of interaction. Ongoing assessment is necessary as family dynamics can evolve throughout the illness. Therefore, A is false as family structure assessment is an important initial step, not the last step.