Critical Care Nursing NCLEX Questions

Correct Answer: D

Rationale: The correct answer is D: Initiate CPR and call a code. In this scenario, the patient is critically ill with ventricular tachycardia, a life-threatening arrhythmia. Since there is no "do not resuscitate" order, the appropriate nursing action is to initiate CPR immediately to attempt to restore the patient's cardiac function and circulation. Calling a code will ensure that a team of healthcare providers can respond promptly with necessary interventions. Options A and B involve unnecessary delays in potentially life-saving interventions. Option C is incorrect as withholding intubation can compromise the patient's airway and oxygenation. Thus, option D is the most appropriate action to prioritize the patient's safety and well-being in this critical situation.

Correct Answer: C

Rationale: Rationale: 1. Intermittent Mandatory Ventilation (IMV) allows the patient to breathe spontaneously between the preset mechanical breaths. 2. It provides a set number of breaths per minute while allowing the patient to initiate additional breaths at their own tidal volume. 3. IMV is a partial ventilatory support mode, providing a balance between controlled and spontaneous breathing. 4. Assist/Control Ventilation (A) provides full support with every breath initiated by the patient or the ventilator. 5. Controlled Ventilation (B) does not allow for spontaneous breaths by the patient. 6. Positive End-Expiratory Pressure (D) is a separate mode focusing on maintaining positive pressure at the end of expiration, not providing breaths.

Correct Answer: B

Rationale: Step 1: Influenza can lead to pneumonia as a complication, so getting an annual flu shot can reduce the risk of pneumonia. Step 2: Providing education on the importance of prevention aligns with discharge teaching goals. Step 3: Option A is incorrect as the pneumococcal vaccine doesn't guarantee immunity from all causes of pneumonia. Step 4: Option C is incorrect as cold or drafty places do not directly cause pneumonia. Step 5: Option D is incorrect as having pneumonia once does not confer permanent immunity.

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: 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.