Critical Care Nursing NCLEX Questions

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.

Correct Answer: B

Rationale: The correct answer is B: Liver. The nurse should monitor liver function in this client because acetaminophen is primarily metabolized in the liver. Alcohol abuse can also contribute to liver damage, increasing the risk of liver toxicity from acetaminophen. Monitoring liver function tests like AST, ALT, and bilirubin levels can help detect any liver damage early. Choice A, cardiorespiratory, is not directly related to acetaminophen or alcohol abuse in this scenario. Choice C, sensory, is not relevant to monitoring organ function in this context. Choice D, kidney, is not the primary concern because acetaminophen is mainly metabolized in the liver, and kidney function is not typically affected by acetaminophen use.

Correct Answer: B

Rationale: The correct answer is B: �This injection is being given to prevent blood clots from forming.� Enoxaparin is an anticoagulant used to prevent blood clots. It is administered through injection, not orally (A). Enoxaparin does not dissolve existing blood clots (C). Contacting the primary care provider to discuss the medication is not necessary in this scenario (D). The correct choice emphasizes the purpose of enoxaparin in preventing new blood clots.

Correct Answer: B

Rationale: The correct answer is B because withdrawal is a common psychological response in the dying process. The nurse should explain to the son that his mother's lack of response may be her way of preparing to leave life. This response validates the son's concerns while providing reassurance. Choice A is incorrect because cutting back visits may not address the underlying issue of the mother's withdrawal. Choice C is incorrect because stimulating the mother may not be beneficial or appropriate in this situation. Choice D is incorrect because not all patients experience a lack of awareness at the end of life, and assuming so may not be helpful in this context.

Correct Answer: B

Rationale: The correct answer is B: Art therapy. Art therapy can help critically ill patients express emotions, reduce anxiety, and cope with pain in a nonverbal way. It provides a creative outlet for self-expression and can improve overall well-being. Anaerobic exercise (A) may not be suitable for critically ill patients due to physical limitations. Guided imagery (C) may not be effective for all patients and requires a certain level of cognitive ability. Music therapy (D) can be beneficial, but art therapy is specifically known for its effectiveness in addressing emotional and psychological needs in critically ill patients.