Critical Care Nursing NCLEX Questions

Correct Answer: C

Rationale: The correct answer is C (80 mL/hour) because the minimum acceptable urine output for a patient is approximately 0.5-1 mL/kg/hour. For a 75 kg patient, this equates to 37.5-75 mL/hour. Therefore, an output of 80 mL/hour is within this range and is considered minimally acceptable. A: Less than 30 mL/hour is incorrect because it is below the recommended range for a 75 kg patient. B: 37 mL/hour is close to the lower end of the acceptable range, but it is not the minimum acceptable output. D: 150 mL/hour is above the recommended range and would be considered excessive for a 75 kg patient.

Correct Answer: E

Rationale: Step 1: The scenario describes a decision made based on the patient's previously expressed wishes. Step 2: The decision aligns with the principle of respecting patient autonomy. Step 3: The term that best describes this situation is "Advance Directive." Summary: - A: Incorrect, as it involves actively ending the patient's life without their consent. - B: Incorrect, as euthanasia involves intentionally causing death to relieve suffering. - C: Incorrect, as palliative care focuses on improving quality of life for the patient. - D: Incorrect, as withdrawal of life support involves discontinuing medical interventions, not honoring the patient's wishes.

Correct Answer: C

Rationale: The correct answer is C: Considers factors related to safe patient care. The scenario involves the nurse discussing the patient's living will with the physician, which is essential for ensuring safe patient care by following the patient's preferences. This aligns with the AACN standard of considering factors related to safe patient care, as the nurse is actively involving all relevant parties in decision-making to provide care that is in line with the patient's wishes. Explanation of why other choices are incorrect: A: Acquires and maintains current knowledge of practice - While important, this choice does not directly relate to the scenario where the focus is on safe patient care through communication and collaboration. B: Acts ethically on behalf of the patient and family - While ethics are important, the scenario is more about following the patient's wishes as outlined in the living will rather than making ethical decisions. D: Uses clinical inquiry and integrates research findings in practice - While valuable in nursing practice, this choice does not directly apply to the scenario where

Correct Answer: D

Rationale: The correct answer is D: Initiate CPR and call a code. In this scenario, the patient is critically ill with ventricular tachycardia, a life-threatening arrhythmia. Since there is no "do not resuscitate" order, the appropriate nursing action is to initiate CPR immediately to attempt to restore the patient's cardiac function and circulation. Calling a code will ensure that a team of healthcare providers can respond promptly with necessary interventions. Options A and B involve unnecessary delays in potentially life-saving interventions. Option C is incorrect as withholding intubation can compromise the patient's airway and oxygenation. Thus, option D is the most appropriate action to prioritize the patient's safety and well-being in this critical situation.

Correct Answer: B

Rationale: The correct answer is B: Discontinue the catheter and culture the tip. The patient's symptoms indicate a possible catheter-related infection. Discontinuing the catheter will prevent further infection spread. Culturing the tip will identify the specific pathogen causing the infection, guiding appropriate antibiotic therapy. Choice A is incorrect because giving analgesics alone will not address the underlying infection. Choice C is incorrect as changing the flush system is not a priority when infection is suspected. Choice D is incorrect as checking the site more frequently does not address the need for immediate action to address the infection.