Critical Care Nursing Practice Questions

Questions 81

ATI RN

ATI RN Test Bank

Critical Care Nursing Practice Questions Questions

Question 1 of 5

Which statement is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.)

Correct Answer: B

Rationale: The correct answer is B. Implementing a comprehensive oral care program is an intervention for preventing VAP. This statement is true because proper oral care, including brushing teeth, oral suctioning, and using chlorhexidine gluconate, has been shown to reduce the risk of VAP by decreasing the colonization of pathogenic bacteria in the oral cavity. Regular oral care helps maintain oral hygiene and reduce the risk of aspiration of bacteria into the lungs, which is a common cause of VAP. Incorrect Answer Analysis: A: Tooth brushing every 2 hours may be excessive and could potentially cause harm to the oral mucosa, leading to increased risk of infection. C: While oral suctioning and brushing teeth are important components of oral care, the statement is not comprehensive enough to address the full range of interventions needed to prevent VAP. D: While chlorhexidine gluconate can be effective in preventing VAP, the statement implies that it is the only effective intervention, which is not true.

Question 2 of 5

When it is noted that a patient�s endotracheal tube is not se cured tightened, he respiratory care practitioner assists the nurse in taping the tube. After the tu be is retaped, the nurse auscultates the patient�s lungs and notes that the breath sounds over the left lung fields are absent. The nurse suspects is the cause of this finding?

Correct Answer: A

Rationale: The correct answer is A: The endotracheal tube is in the right mainstem bronchus. When the endotracheal tube is not secured properly and is retaped, there is a possibility that it may have migrated into the right mainstem bronchus, leading to absent breath sounds in the left lung fields. This condition is known as endobronchial intubation. In such cases, ventilation primarily occurs in the right lung, resulting in decreased or absent breath sounds on the contralateral side. Choices B, C, and D are incorrect as they do not explain the absence of breath sounds over the left lung fields in this specific scenario.

Question 3 of 5

A 19-year-old is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. The nurse will anticipate giving:

Correct Answer: D

Rationale: The correct answer is D because the patient has a high-risk wound (tissue avulsion) and no documented prior tetanus vaccination. TIG provides immediate passive immunity to tetanus, while Tdap stimulates active immunity. TIG covers immediate needs, while Tdap ensures long-term immunity. Choice A (TIG only) does not provide long-term immunity. Choice B (TIG and Td) does not include pertussis coverage, which Tdap (Choice D) does. Choice C (Tdap only) does not cover immediate needs as TIG does.

Question 4 of 5

The patient is admitted with acute kidney injury from a postrenal cause. Acceptable treatments for that diagnosis include: (Select all that apply.)

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.

Question 5 of 5

Daily weights are being recorded for the patient with a urine output that has been less than the intravenous and oral intake. The weight yesterday was 97.5 kg. This morning it is 99 kg. The nurse understands that this corresponds to a(n)

Correct Answer: A

Rationale: The correct answer is A: fluid retention of 1.5 liters. The weight gain from 97.5 kg to 99 kg indicates an increase in fluid retention. This difference of 1.5 kg corresponds to fluid retention of 1.5 liters, as 1 liter of water weighs approximately 1 kg. This weight gain suggests that the patient is retaining more fluid than they are excreting, leading to an increase in weight. Incorrect choices: B: fluid loss of 1.5 liters - This is incorrect because the weight increased, indicating fluid retention. C: equal intake and output due to insensible losses - This is incorrect as weight increased, showing an imbalance in intake and output. D: fluid loss of 0.5 liters - This is incorrect as the weight increased, indicating fluid retention, not loss.

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