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: B

Rationale: The correct answer is B: Assess neurological status every 30 minutes. This intervention is crucial for patients receiving neuromuscular blocking agents to monitor for any adverse effects such as respiratory depression or paralysis. Regular assessments help ensure early detection of complications and prompt intervention. A: Administering sedatives in conjunction with neuromuscular blocking agents can potentiate respiratory depression and lead to respiratory compromise. C: Avoiding interaction with the patient is not appropriate as communication and patient interaction are important aspects of nursing care. D: Restraint should be avoided as it can increase the risk of complications such as pressure ulcers, anxiety, and decreased respiratory function. Overall, regular neurological assessments are essential for ensuring patient safety and prompt intervention in case of any complications.

Correct Answer: B

Rationale: The correct answer is B because assessing the hemofilter every 6 hours for clotting is essential in ensuring the effectiveness of CRRT. Clotting can obstruct blood flow, leading to treatment inefficiency and potential harm to the patient. This step helps the nurse to promptly address any clotting issues and prevent complications. A: Assessing that the blood tubing is warm to the touch is not a standard practice for monitoring CRRT and does not provide relevant information about the treatment's effectiveness. C: Covering the dialysis lines to protect them from light is not a priority in monitoring CRRT. Light exposure is not a common concern in this context. D: Using clean technique during vascular access dressing changes is important for infection prevention but is not directly related to monitoring the effectiveness of CRRT.

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: 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.