ATI RN
Critical Care Nursing Practice Questions Questions
Question 1 of 5
Which of the following assists the critical care nurse in ensuring that care is appropriate and based on research?
Correct Answer: A
Rationale: The correct answer is A: Clinical practice guidelines. Clinical practice guidelines are evidence-based recommendations that assist nurses in providing appropriate care based on research. They outline best practices for specific patient populations or conditions, helping nurses make informed decisions. Summary: - B: Computerized physician order entry: While it may improve accuracy and efficiency, it does not specifically ensure care based on research. - C: Consulting with advanced practice nurses: While collaboration is valuable, it does not guarantee care based on research. - D: Implementing Joint Commission National Patient Safety Goals: Important for patient safety, but not directly related to ensuring care based on research.
Question 2 of 5
The nurse identifies a client's needs and formulates the nursing problem of, 'Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months.' Which short-term goal is best for this client?
Correct Answer: B
Rationale: The correct short-term goal for the client with imbalanced nutrition is choice B: Eat 50% of six small meals each day by the end of one week. This goal is specific, measurable, achievable, relevant, and time-bound (SMART). By setting a goal for the client to eat a specific amount of meals within a defined timeframe, it allows for objective monitoring of progress. This goal also addresses the client's decreased intake and aims to improve their nutritional status gradually. Choice A is incorrect as verbalizing understanding does not directly address the client's nutritional needs. Choice C is not appropriate as it does not promote independence in meal consumption. Choice D is not the best short-term goal as it focuses on the outcome of weight gain rather than the process of increasing food intake. Overall, choice B is the most appropriate short-term goal as it targets the client's specific nutritional needs and provides a clear direction for intervention.
Question 3 of 5
The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the patient�s noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the best action by the nurse?
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.
Question 4 of 5
The critical care unit environment is very stressful for patients, families, and staff. What nursing action is directed at reducing environmental stress?
Correct Answer: D
Rationale: The correct answer is D: Maintaining a quiet environment during hours of sleep. This action is directed at reducing environmental stress in the critical care unit because noise and disturbances during sleep can negatively impact patients' rest and recovery. By ensuring a quiet environment, patients can have uninterrupted sleep, which is crucial for healing. Rationale: 1. Constant expert evaluation of patient status (A) may be important but does not directly address environmental stress. 2. Limiting visits to immediate family (B) may hinder patients' emotional support and can be stressful for families. 3. Bathing all patients during hours of sleep (C) may disrupt patients' rest and increase stress levels rather than reduce it.
Question 5 of 5
What is the basic underlying pathophysiology of acute respiratory distress syndrome?
Correct Answer: C
Rationale: The correct answer is C: Damage to the type II pneumocytes, which produce surfactant. Acute respiratory distress syndrome (ARDS) is characterized by damage to the alveolar epithelium, including type II pneumocytes responsible for producing surfactant. Surfactant reduces surface tension in the alveoli, preventing collapse. Damage to type II pneumocytes impairs surfactant production, leading to alveolar collapse and impaired gas exchange. Choices A, B, and D are incorrect because ARDS is not primarily caused by a decrease in white blood cells, damage to the right mainstem bronchus, or decreased capillary permeability.
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