Critical Care Nursing Cardiac Questions

Correct Answer: D

Rationale: The correct answer is D because using an end-tidal CO2 monitor is the most reliable method to confirm correct endotracheal tube placement in the trachea. This method detects exhaled CO2, indicating proper tube placement in the trachea. It is a quick and efficient way to confirm placement without delay, reducing the risk of complications. A: Auscultating for bilateral breath sounds is not as reliable because breath sounds may be heard even if the tube is misplaced. B: Obtaining a portable chest x-ray is not the best initial action as it takes time and delays confirming tube placement. C: Observing chest movement may not provide conclusive evidence of proper tube placement and can lead to misinterpretation. In summary, using an end-tidal CO2 monitor is the most accurate and efficient method to verify correct endotracheal tube placement compared to the other options.

Correct Answer: A

Rationale: The correct answer is A: Explain ICU visitation policies and encourage family visits. This is the best course of action because it prioritizes the needs of the family members by providing them with information on visitation policies and encouraging them to visit the patient. This helps establish communication, support, and involvement in the patient's care. It also respects the family's emotional needs during a challenging time. Choices B, C, and D are incorrect: B: Immediately taking the family members to the patient's bedside may overwhelm them and disrupt the patient's care. C: Describing the patient's injuries and care being provided should be done in a more controlled environment to ensure the family's understanding and emotional readiness. D: Inviting the family to a multidisciplinary care conference may be premature without first addressing their immediate concerns and providing support.

Correct Answer: C

Rationale: The correct answer is C: Brain death has occurred if there is no breathing and certain reflexes are absent. Brain death is defined as the irreversible cessation of all functions of the entire brain, including the brainstem. The absence of breathing and certain reflexes, such as no response to painful stimuli or no pupillary response to light, are key indicators of brain death. This definition is crucial for determining eligibility for organ donation. Incorrect choices: A: Brain death occurs if a person is flaccid and unresponsive. Flaccidity and unresponsiveness are not specific criteria for diagnosing brain death. B: If CPR is ineffective in restoring a heartbeat, the brain cannot function. The absence of a heartbeat alone does not indicate brain death. D: If respiratory efforts cease and no apical pulse is audible, brain death is present. Respiratory cessation and the absence of pulse are not definitive signs of brain death.

Correct Answer: B

Rationale: The correct answer is B because after 5 days, the risk of infection increases. Evaluating the patient for signs and symptoms of infection is crucial for early detection and treatment. Choice A is incorrect because routine dialysis catheter changes are not necessary after only 5 days. Choice C is incorrect as percutaneous catheters are for short-term use. Choice D is incorrect as using the catheter for fluid administration may increase the risk of infection.

Correct Answer: B

Rationale: The correct answer is B: Change in sputum characteristics. This is a cue for postoperative pneumonia in a COPD patient because it can indicate an infection in the lungs. Postoperative pneumonia is a common complication in patients with COPD due to impaired lung function and weakened immune system. Other choices are incorrect: A) Bradycardia is not a specific indicator of postoperative pneumonia. C) Hypoventilation and respiratory acidosis can be seen in patients with COPD but are not specific to postoperative pneumonia. D) Pursed-lip breathing is a coping mechanism for patients with COPD and is not directly related to postoperative pneumonia.