Critical Care Nursing Questions and Answers PDF

Correct Answer: C

Rationale: Step-by-step rationale for why choice C is correct: 1. Going to the patient�s bedside is the priority as it allows the nurse to assess the patient's condition directly. 2. By being at the bedside, the nurse can quickly evaluate the patient's breathing, vital signs, and other indicators for immediate action. 3. Direct assessment enables timely intervention and avoids delays in addressing potential life-threatening situations. 4. Checking for possible causes of the alarm and reconnection to the ventilator can follow, but assessing the patient's immediate needs takes precedence. In summary, choice C is correct because direct patient assessment is the fundamental step in responding to a ventilator alarm to ensure patient safety and timely intervention. Choices A, B, and D are incorrect as they focus on troubleshooting and technical aspects before directly assessing the patient's condition.

Correct Answer: C

Rationale: The correct answer is C: Rhinorrhoea or otorrhoea with Halo sign. This finding is consistent with a basilar skull fracture because it indicates a cerebrospinal fluid (CSF) leak from the skull base. The Halo sign refers to a ring of CSF surrounded by blood, which can be seen on a white absorbent pad. This specific sign is a classic indicator of a basilar skull fracture, as the CSF leakage from the ears or nose can be tinged with blood due to the fracture disrupting nearby blood vessels. For the other choices: A: Hematemesis and abdominal distention are not typical manifestations of a basilar skull fracture. They are more indicative of gastrointestinal issues or internal bleeding. B: Asymmetry of the face and eye movements can be seen with facial nerve or orbital injuries, but it is not specific to a basilar skull fracture. D: Abnormal position and movement of the arm are not directly related to a

Correct Answer: A

Rationale: The correct answer is A: Assessing the patient's level of pain. In this situation, the patient's tachycardia, hypertension, and increased respiratory rate could be indicative of pain. By assessing the patient's pain level, the nurse can address any discomfort the patient may be experiencing, which could be contributing to these physiological responses. Summary of other choices: B: Decreasing the SIMV rate on the ventilator - This is not the priority intervention as the patient's symptoms are more likely related to pain rather than the ventilator settings. C: Providing sedation as ordered - Sedation is not the priority in this case as the patient has been tolerating the ventilator well without requiring sedation. D: Suctioning the patient again - Since the airway has been recently cleared, suctioning again is not necessary at this point and would not address the underlying cause of the patient's symptoms.

Correct Answer: C

Rationale: The correct answer is C: Listen to the patient�s breath sounds. Moving from 22 cm to 25 cm may indicate ET tube migration. Checking breath sounds can confirm proper tube placement. A may not address the underlying issue. B could worsen the situation if the tube is misplaced. D is not urgent compared to assessing airway integrity.

Correct Answer: C

Rationale: The most appropriate nursing action in this scenario is choice C: Provide support for the patient�s decision and ensure comfort measures. This is because the patient is in hospice care, indicating a focus on comfort and quality of life rather than aggressive treatments. By respecting the patient�s decision and providing comfort measures, the nurse promotes dignity and autonomy. Choices A and B are not suitable as they go against the patient's wishes and may cause distress. Choice D, while important, is not the immediate priority when the patient is not in pain and has chosen to refuse food and fluids. Overall, choice C aligns with the principles of hospice care and prioritizes the patient's comfort and autonomy.