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 for Correct Answer (C): When the low-pressure alarm sounds for a patient with an arterial line, the nurse should assess for cardiac dysrhythmias first. This is because a sudden drop in pressure could indicate a serious issue affecting the heart's ability to pump effectively. Identifying and addressing any cardiac dysrhythmias promptly is crucial for patient safety. Summary of Incorrect Choices: A: Fast flush of the arterial line - This would not address the underlying cause of the low-pressure alarm and may not be necessary. B: Check the left hand for pallor - While assessing perfusion is important, it is not the priority when the alarm indicates a potential cardiac issue. D: Rezero the monitoring equipment - While important for accuracy, it is not the priority when the alarm indicates a potential cardiac concern.

Correct Answer: A

Rationale: Step 1: Symptoms of weight loss, racing heart rate, and difficulty sleeping are common in hyperthyroidism. Step 2: Presence of moist skin, fine hair, prominent eyes, lid retraction, and staring expression are classic signs of Grave's disease, a type of hyperthyroidism. Step 3: Grave's disease is an autoimmune disorder where the thyroid gland is overactive, leading to excessive production of thyroid hormones. Step 4: Excess thyroid hormones increase metabolic rate, causing weight loss, racing heart rate, and insomnia. Step 5: Therefore, the findings described in the question are consistent with Grave's disease.

Correct Answer: A

Rationale: Step 1: Families benefit by witnessing that everything possible was done during resuscitation and invasive procedures. Step 2: This reassures families that healthcare providers are doing their best to save the patient. Step 3: It can provide closure and comfort to families knowing that all efforts were made. Step 4: This transparency can also help in the grieving process for families. Summary: Choice A is correct because it highlights the emotional and psychological benefits for families. Choices B, C, and D are incorrect as they do not align with the positive impacts of allowing family presence during resuscitation and invasive procedures.

Correct Answer: D

Rationale: The correct answer is D. The patient receiving IV heparin with a PTT of 98 seconds is at risk for bleeding due to the therapeutic range of 60-80 seconds. Assessing this patient first is crucial to prevent potential bleeding complications. A high PTT indicates the blood is not clotting properly, increasing the risk of bleeding. Prompt assessment and possible adjustment of heparin infusion are needed. A: The patient with a temperature of 101.4�F may have a fever but is not at immediate risk compared to the patient with a high PTT. B: The patient on BiPAP with a respiratory rate of 16 is stable and does not require immediate assessment. C: The patient post-percutaneous coronary intervention needing to void is a routine need and does not require immediate attention compared to the patient with a critical lab value.