Critical Care Nursing NCLEX Questions

Correct Answer: B

Rationale: Step 1: Start with Background - statement B provides relevant background information about the patient's current condition and why there is a need for communication. Step 2: Move on to Situation - statement D sets the current situation where the nurse expresses concern about the patient's symptom. Step 3: Next is Assessment - statement C details the nurse's assessment findings, highlighting the critical aspects of the patient's condition. Step 4: End with Recommendation - statement A suggests the necessary action to be taken based on the assessment findings. This order ensures a clear and structured communication process. Summary: - Choice A is incorrect as the recommendation should come after providing background, situation, and assessment. - Choice C is incorrect as assessment details should precede the patient's critical condition. - Choice D is incorrect as the situation should be explained before expressing concern.

Correct Answer: A

Rationale: Step 1: Families benefit by witnessing that everything possible was done during resuscitation and invasive procedures. Step 2: This reassures families that healthcare providers are doing their best to save the patient. Step 3: It can provide closure and comfort to families knowing that all efforts were made. Step 4: This transparency can also help in the grieving process for families. Summary: Choice A is correct because it highlights the emotional and psychological benefits for families. Choices B, C, and D are incorrect as they do not align with the positive impacts of allowing family presence during resuscitation and invasive procedures.

Correct Answer: A

Rationale: The correct answer is A because pain and anxiety trigger the sympathetic nervous system's fight-or-flight response, increasing heart rate, blood pressure, and stress hormones to prepare the body for potential danger. This physiological response helps the individual respond to perceived threats. Choices B, C, and D are incorrect because pain and anxiety typically increase stress levels, do not necessarily remove one from harm, and can hinder rather than enhance performance due to distraction and decreased focus.

Correct Answer: B

Rationale: The correct answer is B because a mechanically ventilated patient with cardiogenic shock being treated with an intra-aortic balloon pump would benefit most from having a Vigileo pulse contour cardiac output monitoring system. This device provides continuous cardiac output monitoring and can help guide hemodynamic management in critically ill patients, especially those with hemodynamic instability like cardiogenic shock. It allows for real-time adjustments of fluid and vasoactive medications to optimize cardiac output and tissue perfusion. Choice A is incorrect because a patient with a history of aortic insufficiency and postoperative myocardial infarction may not require continuous cardiac output monitoring like the patient in choice B. Choice C is incorrect as the patient with atrial fibrillation and paroxysmal supraventricular tachycardia does not necessarily need cardiac output monitoring. Choice D is also incorrect as a mechanically ventilated patient following repair of an acute bowel obstruction may not require continuous cardiac output monitoring unless there are specific complications.

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.