Critical Care Nursing Questions and Answers PDF

Questions 81

ATI RN

ATI RN Test Bank

Critical Care Nursing Questions and Answers PDF Questions

Question 1 of 5

The nurse is preparing for insertion of a pulmonary artery acbairtbh.ceotme/rte (sPt AC). During insertion of the catheter, what are the priority nursing actions? (Select all that apply.)

Correct Answer: B

Rationale: The correct answer is B: Ensure that a sterile field is maintained during the insertion procedure. This is the priority nursing action because maintaining a sterile field is crucial to prevent infection during the invasive procedure. The nurse must follow strict aseptic technique to reduce the risk of introducing bacteria into the patient's bloodstream. All other choices are incorrect: A: Addressing the patient's anxiety is important but not the priority during the insertion procedure. C: Inflating the balloon is a specific action that should be performed by the physician, not the nurse. D: While monitoring the patient's cardiac rhythm is important, ensuring the sterile field takes precedence to prevent complications.

Question 2 of 5

The emergency department (ED) nurse is initiating therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/LVN) (select all that apply)?

Correct Answer: D

Rationale: Correct Answer: D - Give acetaminophen (Tylenol) 650 mg per nasogastric tube. Rationale: LPNs/LVNs are trained to administer medications, including oral and nasogastric routes. Giving acetaminophen via nasogastric tube is within their scope of practice. LPNs/LVNs should have the knowledge and skills to safely administer this medication as part of the hypothermia protocol. Summary of other choices: A: Continuously monitor heart rhythm - This requires specialized training and skills typically within the scope of registered nurses or cardiac monitoring technicians. B: Check neurologic status every 2 hours - Assessing neurologic status requires critical thinking and clinical judgment, which are typically responsibilities of registered nurses. C: Place cooling blankets above and below the patient - Positioning and managing cooling devices may require specific training and should be done under the supervision of a registered nurse.

Question 3 of 5

A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with a basilar skull fracture?

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

Question 4 of 5

The critical care unit environment is very stressful for patients, families, and staff. What nursing action is directed at reducing environmental stress?

Correct Answer: D

Rationale: The correct answer is D: Maintaining quiet during hours of sleep. This action is essential in reducing environmental stress in the critical care unit as it promotes a restful environment for patients and allows for better sleep quality. Noise can disrupt sleep patterns and increase stress levels. Constant evaluation of patient status (A) is important but does not directly address environmental stress. Limiting visits to immediate family (B) can be beneficial in some cases but may not always reduce environmental stress. Bathing all patients during hours of sleep (C) may actually increase stress as it can be disruptive and uncomfortable for patients. Overall, maintaining a quiet environment during sleep hours is the most effective nursing action to reduce environmental stress in the critical care unit.

Question 5 of 5

The nurse is caring for a very seriously ill patient in the CCU. The family visits sporadically, stays for only a short time, and does not ask many questions. How could the nurse best begin to involve the family in the patients care?

Correct Answer: D

Rationale: The correct answer is D: Ask the family to complete the Critical Care Family Needs Inventory. This tool helps assess the family's needs and concerns, enabling the nurse to tailor care accordingly. By understanding the family's specific needs, the nurse can provide appropriate support and information, fostering better involvement and understanding. A: Asking one family member to assist with the patient's bath may not address the overall family's needs or involvement in care. B: Encouraging family members to stay longer does not necessarily address their specific needs or facilitate effective communication. C: Focusing solely on the legal next of kin may exclude important family members who also need support and involvement in the patient's care.

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