Critical Care Nursing Practice Questions

Correct Answer: D

Rationale: The correct answer is D: Richmond Agitation Sedation Scale (RASS). RASS is specifically designed to monitor agitation and sedation levels in critically ill patients, providing a standardized and objective assessment. It includes clear descriptors for different levels of agitation and sedation, allowing for consistent monitoring and treatment adjustments. CAM-ICU is mainly used for delirium assessment, not agitation. FACES assessment tool is more appropriate for pain assessment. Glasgow Coma Scale is focused on assessing level of consciousness, not agitation specifically. By using RASS, healthcare providers can accurately track agitation levels and evaluate the effectiveness of interventions in managing agitation in critically ill patients.

Correct Answer: C

Rationale: Rationale for Correct Answer (C - Assess the cuff for proper arm size): 1. The cuff blood pressure (70/40 mm Hg) is significantly lower than the arterial blood pressure (108/70 mm Hg). 2. Discrepancy suggests cuff size mismatch, leading to inaccurate readings. 3. Assessing cuff size ensures accurate blood pressure measurement. 4. Ensures appropriate interventions based on accurate readings. Summary of Incorrect Choices: A: Rapid response not warranted based solely on blood pressure discrepancy. B: Trendelenburg position not indicated for cuff size issue. D: Normal saline bolus not appropriate without accurate blood pressure measurement.

Correct Answer: B

Rationale: The correct answer is B because effective communication ensures that the patient's wishes and values are understood and respected, leading to informed decision-making. It also promotes shared decision-making among the patient, family, and healthcare team, enhancing the quality of care. Choices A, C, and D are incorrect because while they are important aspects of end-of-life care, they do not address the core element of communication in facilitating meaningful and informed decisions.

Correct Answer: A

Rationale: The correct answer is A: Autonomy. Autonomy is the ethical principle that respects an individual's right to make decisions about their own care and treatment. In this scenario, the partner wanting "everything done" regardless of the patient's wishes violates the patient's autonomy by not honoring their previously expressed wishes outlined in the living will. This decision disregards the patient's right to make choices about their own healthcare. Choices B, C, and D are incorrect because: B: Beneficence focuses on doing good for the patient, but in this case, the partner's actions are not necessarily in the patient's best interest. C: Justice pertains to fairness and equal treatment, which is not directly relevant to the situation described. D: Nonmaleficence is the principle of doing no harm, but in this scenario, the harm is not necessarily physical but rather a violation of the patient's autonomy.

Correct Answer: A

Rationale: Step-by-step rationale: 1. Bladder catheterization helps relieve urinary obstruction, a common postrenal cause of acute kidney injury. 2. By draining urine from the bladder, it prevents further damage to the kidneys. 3. This intervention addresses the underlying cause of the kidney injury, leading to improvement. Summary: - Choice A is correct as it directly addresses the postrenal cause by relieving urinary obstruction. - Choices B, C, and D are incorrect as they do not target the specific postrenal cause of acute kidney injury.