Critical Care Nursing Practice Questions

Correct Answer: C

Rationale: Step-by-step rationale for choice C: 1. Activity intolerance is a priority nursing problem postoperatively due to pain. 2. Postoperative pain can limit the client's ability to perform activities. 3. Addressing activity intolerance is crucial for promoting recovery and preventing complications. 4. Delaying the teaching session helps the nurse focus on managing pain first. Summary of why other choices are incorrect: - Choice A: Knowledge deficit can be addressed after managing immediate postoperative issues. - Choice B: Treatment regimen management is important but may not be as urgent as addressing activity intolerance related to pain. - Choice D: Noncompliance with exercise plan can be addressed once the client's pain and activity intolerance are under control.

Correct Answer: C

Rationale: Step 1: Comfort care is focused on providing relief from suffering and improving quality of life. Step 2: Patient-centered care emphasizes the individual's preferences and values. Step 3: Patient autonomy is a fundamental principle in healthcare decision-making. Step 4: Patients have the right to determine what constitutes comfort care for themselves. Step 5: Therefore, statement C is correct as it aligns with the patient's autonomy and individualized care approach. Summary: - Choice A is incorrect because legal distinctions between withholding and withdrawing treatment may vary. - Choice B is incorrect as it focuses on evaluating procedures rather than the patient's preferences. - Choice D is incorrect as withdrawing life-sustaining treatments is not universally considered euthanasia.

Correct Answer: C

Rationale: The correct answer is C: Notify the health care provider and postpone the transfer. The new onset confusion in an elderly patient in the ICU can be a sign of delirium, which is a serious condition that requires prompt evaluation and management. By notifying the healthcare provider, they can assess the patient's condition, order appropriate tests, and adjust the treatment plan as needed. Postponing the transfer allows for further observation and intervention to address the underlying cause of the confusion. Choice A (Give PRN lorazepam and cancel the transfer) is incorrect because administering lorazepam may worsen the confusion in an elderly patient and should not be done without proper evaluation. Choice B (Inform the receiving nurse and then transfer the patient) is incorrect because transferring the patient without addressing the new onset confusion can lead to potential complications and delay in appropriate management. Choice D (Obtain an order for restraints as needed and transfer the patient) is incorrect because using restraints should only be considered as a

Correct Answer: A

Rationale: The correct answer is A: The endotracheal tube is in the right mainstem bronchus. When the endotracheal tube is not secured properly and is retaped, there is a possibility that it may have migrated into the right mainstem bronchus, leading to absent breath sounds in the left lung fields. This condition is known as endobronchial intubation. In such cases, ventilation primarily occurs in the right lung, resulting in decreased or absent breath sounds on the contralateral side. Choices B, C, and D are incorrect as they do not explain the absence of breath sounds over the left lung fields in this specific scenario.

Correct Answer: D

Rationale: The correct answer is D: Attach cardiac monitoring leads before the procedure. This is essential to monitor the patient's cardiac rhythm and detect any abnormalities during catheter insertion. Cardiac monitoring leads provide real-time information on the patient's heart rate and rhythm, allowing the nurse to promptly address any complications. A: Determining if the cardiac troponin level is elevated is not directly related to assisting with pulmonary artery catheter insertion. B: Auscultating heart and breath sounds during insertion is important but does not take precedence over attaching cardiac monitoring leads. C: Placing the patient on NPO status before the procedure may be necessary for other procedures, but it is not specifically required for assisting with pulmonary artery catheter insertion.