Critical Care Nursing NCLEX Questions

Correct Answer: A

Rationale: The correct answer is A: contact the provider and expect a prescription for a normal saline bolus. The patient is showing signs of hypovolemia with decreased urine output, low blood pressure, and elevated heart rate. This indicates inadequate perfusion and potential hypovolemic shock. Administering a normal saline bolus will help restore intravascular volume and improve perfusion. Waiting for the provider to make rounds (option B) could delay necessary intervention. Continuing to evaluate urine output for 2 more hours (option C) is not appropriate given the patient's current condition. Ignoring the urine output (option D) is dangerous as it could lead to further complications.

Correct Answer: A

Rationale: The correct answer is A: Agitation. In hyperactive delirium, patients often exhibit restlessness, agitation, and hyperactivity. This behavior is a key characteristic indicating hyperactive delirium. Apathy (B), biting (C), and hitting (D) are not typically associated with hyperactive delirium. Apathy may be seen in hypoactive delirium, while biting and hitting are not specific indicators of delirium subtypes. Therefore, the correct choice is A as it aligns with the typical presentation of hyperactive delirium.

Correct Answer: D

Rationale: Ultrafiltration is the correct answer because it involves the removal of plasma water and low-molecular weight particles by using a pressure or osmotic gradient. During ultrafiltration, the pressure gradient pushes the fluid through a semipermeable membrane, separating the substances based on their molecular size. This process allows for the selective removal of unwanted substances while retaining essential components. Dialysis (choice A) involves the removal of waste products from the blood, but it does not specifically target plasma water and low-molecular weight particles. Diffusion (choice B) is the passive movement of particles from an area of higher concentration to an area of lower concentration and is not specific to the removal of plasma water. Clearance (choice C) refers to the rate at which a substance is removed from the blood and does not involve the mechanism of pressure or osmotic gradient utilized in ultrafiltration.

Correct Answer: B

Rationale: Step 1: Influenza can lead to pneumonia as a complication, so getting an annual flu shot can reduce the risk of pneumonia. Step 2: Providing education on the importance of prevention aligns with discharge teaching goals. Step 3: Option A is incorrect as the pneumococcal vaccine doesn't guarantee immunity from all causes of pneumonia. Step 4: Option C is incorrect as cold or drafty places do not directly cause pneumonia. Step 5: Option D is incorrect as having pneumonia once does not confer permanent immunity.

Correct Answer: B

Rationale: The elevated BUN and creatinine levels with a normal BUN/creatinine ratio indicate impaired kidney function. This pattern is commonly seen in acute kidney injury, such as acute tubular necrosis (ATN). In ATN, there is damage to the renal tubules leading to decreased excretion of waste products, resulting in elevated BUN and creatinine levels. The normal BUN/creatinine ratio suggests that the impairment is due to renal tubular dysfunction rather than prerenal causes like hypovolemia or postrenal causes like urinary obstruction. Increased nitrogen intake would not produce this specific pattern of results. Fluid resuscitation would likely result in dilution of BUN and creatinine levels, leading to lower values.