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: B

Rationale: The correct answer is B: Apply pressure to the insertion site for 5 minutes. This is the priority nursing action because it helps prevent bleeding and hematoma formation after removing the arterial line. Applying pressure for 5 minutes allows for adequate hemostasis. A: Applying an air occlusion dressing to the insertion site is not the priority action. It does not address the immediate need to control bleeding. C: Elevating the affected limb on pillows for 24 hours is not necessary and does not address the immediate need for hemostasis. D: Keeping the patient's wrist in a neutral position is not the priority action when discontinuing an arterial line. It does not address the need for hemostasis and preventing bleeding.

Correct Answer: C

Rationale: The correct answer is C because a pulmonary artery occlusion pressure of 25 mm Hg indicates possible fluid overload or cardiac issue requiring urgent evaluation. This value is high, suggesting increased pressure in the left side of the heart. Additionally, the oxygen saturation of 89% on 3 L of oxygen indicates potential respiratory compromise. This patient needs immediate assessment and intervention to prevent worsening of their condition. Choice A is incorrect as a central venous pressure of 6 mm Hg is within normal limits, and the urine output is adequate. Choice B is incorrect as a BP of 110/60 mm Hg is acceptable, and a slightly dampened arterial waveform is not an immediate concern. Choice D is incorrect as a pulmonary artery pressure of 25/10 mm Hg is within normal range, and an oxygen saturation of 94% on 2 L of oxygen is acceptable.

Correct Answer: C

Rationale: The correct answer is C: Safety. In hyperactive delirium, the patient may be agitated, disoriented, and at risk of harm. Safety is the priority to prevent falls or injury. Comfort (A) is important but secondary to safety in this case. Nourishment (B) can wait until safety is ensured. Sedation (D) may be considered but only after safety measures are in place.

Correct Answer: C

Rationale: The correct answer is C: Severe pain. In the second phase of the stress response (resistance phase), the body is trying to cope with the stressor. Severe pain is a sign of the body's response to the injury, indicating the activation of the stress response. Labored breathing and elevated heart rate are more likely to be signs of the initial phase (alarm phase) of the stress response. Bleeding heavily from the abdomen is a medical emergency and does not specifically indicate the stress response phase.