Critical Care Nursing Exam Questions

Correct Answer: B

Rationale: The correct answer is B: Restlessness. When the body experiences hypoxemia (low oxygen levels), the brain is deprived of oxygen, leading to early signs such as restlessness. This is due to the brain's attempt to increase oxygen intake by increasing activity. Cyanosis (A) is a late sign of hypoxemia when oxygen levels are critically low. Tachycardia (C) and tachypnea (D) are compensatory mechanisms in response to hypoxemia, but they are not early signs affecting the nervous system directly.

Correct Answer: A

Rationale: The correct answer is A, hypotension. During hemodialysis for acute kidney injury, fluid removal can lead to hypotension due to rapid changes in blood volume. This can cause dizziness, weakness, and even loss of consciousness. Dysrhythmias (choice B) are less common but can occur due to electrolyte imbalances. Muscle cramps (choice C) may occur during or after dialysis due to electrolyte imbalances or fluid shifts, but they are not as common as hypotension. Hemolysis (choice D) is not a common complication of hemodialysis for acute kidney injury, as it is more commonly associated with issues related to the dialysis machine or blood tubing.

Correct Answer: D

Rationale: The correct answer is D because it shows empathy and promotes patient education. By describing the procedure and its necessity, the nurse can alleviate the patient's anxiety and build trust. This approach allows the patient to feel informed and in control, reducing fear and increasing cooperation. It also demonstrates respect for the patient's feelings and promotes a therapeutic relationship. Choice A is incorrect as it disregards the patient's fear and can lead to increased distress. Choice B might be an option, but it doesn't address the patient's anxiety in the moment. Choice C, while helpful in some cases, doesn't directly address the patient's specific fear of the blood draw procedure.

Correct Answer: C

Rationale: Rationale for Correct Answer C: Endotracheal suctioning should be done as indicated by patient assessment because not all patients require routine suctioning. Performing unnecessary suctioning can lead to potential complications such as mucosal damage and increased risk of infection. Therefore, the nurse must assess the patient's respiratory status, auscultate lung sounds, monitor oxygen saturation levels, and observe for signs of increased secretions before deciding to perform suctioning. Summary of Incorrect Choices: A: Endotracheal suctioning does not directly impact intracranial pressure. It is primarily focused on maintaining airway patency and removing respiratory secretions. B: While endotracheal suctioning may temporarily suppress the cough reflex during the procedure, its primary purpose is to clear airway secretions to prevent complications such as atelectasis and respiratory distress. D: Saline instillation before suctioning is not recommended as it can lead to negative outcomes such as dehydration, mucosal damage, and increased risk of infection

Correct Answer: A

Rationale: The correct answer is A because the patient in cardiogenic shock with a cardiac output of 2.0 L/min is experiencing a life-threatening condition that requires immediate evaluation. Cardiogenic shock indicates poor cardiac function, which can lead to multi-organ failure. Monitoring cardiac output is crucial in managing these patients. Choice B is incorrect because a pulmonary artery systolic pressure of 20 mm Hg is within normal range and does not indicate an immediate life-threatening condition. Choice C is incorrect because a CVP of 6 mm Hg in a hypovolemic patient may indicate volume depletion, but it is not as urgent as the patient in cardiogenic shock. Choice D is incorrect because a PAOP of 10 mm Hg is within normal range and does not suggest an immediate critical condition.