Critical Care Nursing NCLEX Questions

Correct Answer: C

Rationale: The correct answer is C: Procedures performed in the operating room are associated with fewer complications. This is because performing a tracheostomy in the operating room allows for better control of the environment, equipment, and expertise of the surgical team. In this setting, the risk of complications such as bleeding, infection, and injury to surrounding structures is minimized. Choices A, B, and D are incorrect: A: Patient outcomes are better if the tracheostomy is done within a week of intubation - This statement is not universally true and depends on individual patient factors. Timing of tracheostomy should be based on the patient's clinical condition and not a set timeline. B: Percutaneous tracheostomy can be done safely at the bedside by the respiratory therapist - While percutaneous tracheostomy can be performed at the bedside, it is typically done by a trained physician or surgeon due to the potential risks and complications involved. D: The greatest risk after a per

Correct Answer: D

Rationale: The correct answer is D: Identify the problem. This is the first action the nurse should take in the nursing process as it helps in understanding the client's issue. By identifying the problem, the nurse can gather more information through further assessment to determine the underlying cause of the client's difficulty in walking. This step is crucial for developing an effective care plan and interventions. A: Predict the likelihood of the outcome - This choice is not appropriate as predicting the outcome should come after identifying the problem and implementing interventions. B: Consider alternatives - While considering alternatives is important in the decision-making process, it is not the immediate action needed in this scenario. C: Choose the most successful approach - This choice is premature as the nurse needs to first identify the problem before determining the most successful approach.

Correct Answer: C

Rationale: Step 1: The objective is for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Step 2: Choice C states that the client drinks 240 mL of fluid five times during the shift, totaling 1200 mL (240 mL x 5) which exceeds the required amount. Step 3: Therefore, choice C is the correct answer as it demonstrates successful achievement of the objective by ensuring the client has ingested enough fluid within the specified time frame. Step 4: Choices A, B, and D are incorrect as they do not directly address the specific objective of fluid intake set for the client. Option A focuses on intake and output, option B relates to abdominal comfort, and option D is about voiding, none of which directly address the specified objective of fluid ingestion.

Correct Answer: B

Rationale: The correct answer is B because it acknowledges the partner's feelings while providing information that may help them cope. By stating that unresponsiveness doesn't mean the patient can't hear, the nurse highlights the importance of the partner's presence for emotional support. It encourages the partner to continue visiting, emphasizing their role in providing comfort to the patient. Choice A is incorrect as it dismisses the partner's feelings and lacks empathy. Choice C is incorrect as it implies the nurse will only involve the partner if the patient responds, neglecting the partner's emotional needs. Choice D is incorrect as it deflects responsibility from addressing the partner's concerns and suggests involving other family members without addressing the partner's feelings directly.

Correct Answer: D

Rationale: The correct answer is D. The first step in endotracheal intubation is to insert the endotracheal tube with a laryngoscope and blade to visualize the vocal cords and guide the tube into the trachea. This ensures proper placement of the tube for effective ventilation. Assessing the balloon symmetry (Choice A) and lung fields (Choice B) would come after the tube is successfully inserted. Inflating the balloon of the endotracheal tube (Choice C) should be the last step to secure the tube in place.