Critical Care Nursing NCLEX Questions

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.

Correct Answer: D

Rationale: The correct answer is D because positioning the patient with the head of the bed at 10 degrees is incorrect for a patient receiving mechanical ventilation. The optimal position for such patients is to elevate the head of the bed to 30-45 degrees to prevent aspiration and improve oxygenation. Option A is incorrect as increasing FIO2 before suctioning is appropriate to ensure adequate oxygenation. Option B is incorrect as securing a bite block in place using adhesive tape is a standard practice to prevent the patient from biting on the endotracheal tube. Option C is incorrect as asking for assistance to reposition the endotracheal tube shows the RN is aware of the importance of proper placement to ensure effective ventilation.

Correct Answer: A

Rationale: The correct answer is A: Thirty-degree elevation of the head of the bed. This is the priority nursing intervention for a mechanically ventilated patient following bilateral lung transplantation because it helps optimize ventilation-perfusion matching, reduces the risk of aspiration, and improves oxygenation. Elevating the head of the bed also decreases the risk of ventilator-associated pneumonia. B: Endotracheal suctioning as needed is important but not the priority intervention in this case. C: Frequent side to side repositioning is important for preventing pressure ulcers but is not the priority for a ventilated patient post-lung transplant. D: Sequential compression stockings are used for preventing deep vein thrombosis, which is important but not the priority in this scenario.

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: C

Rationale: Step-by-step rationale for choice C: 1. Advance directives should be made by the patient to reflect their wishes. 2. Developing it before illness ensures clarity and avoids confusion. 3. Patients may not be able to make informed decisions in critical conditions. 4. Family or surrogates may not accurately represent the patient's wishes. Summary: A - Family in critical condition may not know the patient's wishes. B - Hospital admission process may be too late for clear decision-making. D - Healthcare surrogate may not fully understand the patient's preferences.