Critical Care Nursing Questions

Correct Answer: B

Rationale: The correct answer is B: Train-of-four yields two twitches. This assessment indicates a target level of paralysis because a train-of-four ratio of 2 twitches out of 4 suggests a 50% neuromuscular blockade, which is often the goal for patients receiving paralysis for procedures or ventilation. A: A Glasgow Coma Scale score of 3 assesses consciousness, not neuromuscular blockade. C: A Bispectral index of 60 measures depth of anesthesia, not paralysis level. D: CAM-ICU assesses delirium, not neuromuscular blockade.

Correct Answer: B

Rationale: The correct answer is B: Hypoventilation and respiratory acidosis. When a patient overdoses on sedatives, it can lead to respiratory depression causing hypoventilation. Hypoventilation results in retention of CO2, leading to respiratory acidosis. This is because the body is not effectively exhaling CO2, causing an increase in carbonic acid levels and a decrease in blood pH. The other choices are incorrect because hyperventilation would lead to respiratory alkalosis (Choice A), hypoventilation does not cause respiratory alkalosis (Choice C), and normal oxygen levels do not indicate the acid-base imbalance caused by sedative overdose (Choice D).

Correct Answer: D

Rationale: Step 1: Abdominal pain, chills, and elevated temperature suggest a serious complication like visceral perforation. Step 2: Peritoneal dialysate return assessment won't address the potential life-threatening issue. Step 3: Checking blood sugar or evaluating neurological status is not relevant to the presenting symptoms. Step 4: Informing the provider of probable visceral perforation is crucial for prompt intervention and further evaluation.

Correct Answer: B

Rationale: The correct answer is B because applying an insulin sliding scale method based on research is an example of evidence-based practice. This method is derived from scientific evidence and research studies, ensuring the best outcomes for the patient. The other choices lack the same level of evidence-based rationale: A is based on a protocol, which may not be evidence-based; C is a standard safety practice, not necessarily evidence-based; D is a decision based on hospital policy or practicality, not specifically evidence-based.

Correct Answer: B

Rationale: The correct answer is B because evaluating the patient's serum creatinine for up to 72 hours after the procedure is crucial in detecting contrast-induced kidney injury. An increase in serum creatinine levels indicates impaired kidney function due to the contrast dye. This monitoring allows for early detection and intervention to prevent further kidney damage. Choice A is incorrect because a decrease in urine output is a late sign of kidney injury and may not be present in the early stages. Choice C is incorrect as a renal ultrasound is not typically used to detect contrast-induced kidney injury. Choice D is incorrect as postvoid residual volume assessment is not specific to detecting intrarenal injury related to contrast dye use.