Critical Care Nursing NCLEX Questions

Correct Answer: C

Rationale: The correct answer is C because individualized visitation meets the unique needs of patients and family members, promoting holistic care and emotional support. Choice A is incorrect as strictly restricted visiting hours may hinder family involvement in care. Choice B is incorrect as children can provide comfort and support. Choice D is incorrect as unrestricted visiting may disrupt patient rest and care routines.

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: A

Rationale: The correct answer is A: Restlessness. Restlessness is a common behavioral indicator of anxiety in patients. In this scenario, a patient who is orally intubated and on a ventilator may not be able to verbally express anxiety, making restlessness a more prominent sign. Verbalization may not be possible due to intubation. While increased respiratory rate can be a symptom of anxiety, it is also a common physiological response in patients on mechanical ventilation. A Glasgow Coma Scale score of 3 indicates severe impairment of consciousness, not specifically anxiety.

Correct Answer: D

Rationale: The correct answer is D: Identify the problem. This is the first action the nurse should take in the nursing process as it helps in understanding the client's issue. By identifying the problem, the nurse can gather more information through further assessment to determine the underlying cause of the client's difficulty in walking. This step is crucial for developing an effective care plan and interventions. A: Predict the likelihood of the outcome - This choice is not appropriate as predicting the outcome should come after identifying the problem and implementing interventions. B: Consider alternatives - While considering alternatives is important in the decision-making process, it is not the immediate action needed in this scenario. C: Choose the most successful approach - This choice is premature as the nurse needs to first identify the problem before determining the most successful approach.

Correct Answer: B

Rationale: The correct answer is B because certification validates nurses' expert knowledge and practice. This is important as it ensures that nurses have the necessary skills and competence to provide high-quality care in critical care settings. Certification is voluntary and not mandated by government regulations (Choice C). It goes beyond demonstrating basic knowledge (Choice D) by confirming specialized expertise. While certification may garner positive publicity (Choice A), the primary benefit is the validation of advanced skills and knowledge.