Critical Care Nursing NCLEX Questions

Correct Answer: A

Rationale: The correct answer is A: Thirty-degree elevation of the head of the bed. This is the priority nursing intervention for a mechanically ventilated patient following bilateral lung transplantation because it helps optimize ventilation-perfusion matching, reduces the risk of aspiration, and improves oxygenation. Elevating the head of the bed also decreases the risk of ventilator-associated pneumonia. B: Endotracheal suctioning as needed is important but not the priority intervention in this case. C: Frequent side to side repositioning is important for preventing pressure ulcers but is not the priority for a ventilated patient post-lung transplant. D: Sequential compression stockings are used for preventing deep vein thrombosis, which is important but not the priority in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Hypoventilation. A PaCO2 of 48 mm Hg indicates an elevated level of carbon dioxide in the blood, which is typically seen in hypoventilation where the lungs are not effectively removing CO2. Hypoventilation leads to respiratory acidosis. Option A is incorrect because hyperventilation would decrease PaCO2 levels. Option C is incorrect as it does not directly relate to PaCO2 levels. Option D is incorrect as increased excretion of HCO3- would not directly affect PaCO2 levels.

Correct Answer: B

Rationale: The correct answer is B (80 to 125 mL/min) because this range reflects the normal glomerular filtration rate (GFR) in adults. GFR measures the rate at which blood is filtered by the kidneys, typically around 125 mL/min. A GFR below 60 mL/min indicates kidney dysfunction, making option A incorrect. Option C (125 to 180 mL/min) is above the normal range. Option D (more than 189 mL/min) is too high and could indicate hyperfiltration, common in conditions like diabetes. Therefore, choice B is the most appropriate within the normal GFR range.

Correct Answer: C

Rationale: The correct answer is C: Collaboration with patients, families, and team members. By addressing the family's concern about lack of communication with the physician and arranging a meeting between the intensivist and the family, the nurse is demonstrating collaboration skills in facilitating communication and ensuring the family's questions are addressed. This competency emphasizes the importance of working together with patients, families, and the healthcare team to provide optimal care. Incorrect choices: A: Advocacy and moral agency in solving ethical issues - While advocacy is important in nursing, in this scenario, the focus is on communication and collaboration rather than ethical issues. B: Clinical judgment and clinical reasoning skills - Although these skills are crucial in critical care nursing, the situation described does not primarily involve clinical judgment but rather communication and collaboration. D: Facilitation of learning for patients, families, and team members - While patient education is important, the main focus of the scenario is on addressing the family's concerns and facilitating communication, rather than educational aspects.

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.