Critical Care Nursing Exam Questions

Critical Care Nursing Exam Questions Related

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A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most important to discuss with the health care provider before starting the SBT?

  • A. New ST segment elevation is noted on the cardiac monitor.
  • B. Enteral feedings are being given through an orogastric tube.
  • C. Scattered rhonchi are heard when auscultating breath sounds.
  • D. HYDROmorphone (Dilaudid) is being used to treat postoperative pain.
Correct Answer: A

Rationale: The correct answer is A: New ST segment elevation is noted on the cardiac monitor. This finding is concerning because it may indicate myocardial ischemia or infarction, which can be exacerbated by the physiological stress of weaning from mechanical ventilation. It is crucial to address any cardiac issues before initiating a spontaneous breathing trial to prevent potential cardiac complications during the weaning process.

Explanation for why the other choices are incorrect:
B: Enteral feedings being given through an orogastric tube are not contraindicated for starting a spontaneous breathing trial.
C: Scattered rhonchi heard when auscultating breath sounds may indicate retained secretions but are not a contraindication for a spontaneous breathing trial.
D: The use of HYDROmorphone to treat postoperative pain is not a contraindication for a spontaneous breathing trial unless it is causing respiratory depression, which would need to be addressed separately.

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The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased ScvO2, the nurse assesses the patient’s:

  • A. Lipase.
  • B. Temperature.
  • C. Urinary output.
  • D. Body mass index.
Correct Answer: B

Rationale: The correct answer is B: Temperature. Decreased ScvO2 in severe pancreatitis can be due to systemic inflammatory response leading to increased metabolic demand and decreased tissue oxygen delivery. Monitoring temperature helps assess for presence of infection or sepsis, which can further decrease tissue oxygenation. Lipase (A) is specific for pancreatitis diagnosis, not directly related to ScvO2. Urinary output (C) is important for assessing renal function, not directly related to ScvO2. Body mass index (D) does not provide information on tissue oxygenation status in this context.

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient’s left pedal pulse is absent and the leg is swollen. Which action will the nurse take next?

  • A. Send blood to the lab for a complete blood count.
  • B. Assess further for a cause of the decreased circulation.
  • C. Finish the airway, breathing, circulation, and disability survey.
  • D. Start normal saline fluid infusion with a large-bore IV line.
Correct Answer: B

Rationale: The correct answer is B: Assess further for a cause of the decreased circulation. The nurse should prioritize assessing the cause of the absent left pedal pulse and leg swelling to address the severe leg trauma effectively. This step involves identifying potential vascular compromise or compartment syndrome, which are critical conditions requiring immediate intervention. Sending blood for a complete blood count (A) is not the priority in this situation. Finishing the primary survey (C) may delay addressing the circulation issue. Starting normal saline infusion (D) without addressing the circulation problem first could potentially worsen the condition. Therefore, assessing further for the cause of decreased circulation is the most appropriate next step to ensure timely and appropriate management of the patient's condition.

The client has been in the CCU for several weeks and has been very unstable. One family member stays at the bedside constantly and even naps in a bedside chair. The nurse understands that the family member is exhibiting which family member response to critical illness?

  • A. Exhibiting extreme distrust of the health care team
  • B. Seeking evidence for future legal or punitive action
  • C. Trying to maintain a level of control over the situation
  • D. Experiencing extreme fatigue from constant stress
Correct Answer: C

Rationale: The correct answer is C: Trying to maintain a level of control over the situation. The family member staying at the bedside constantly and even napping there is likely trying to cope with the stressful situation by maintaining a sense of control and connection to the patient. This behavior can be a way for the family member to feel more involved and helpful during a time of uncertainty and powerlessness. Choices A and B involve negative assumptions about the family member's intentions without evidence. Choice D may be a result of the family member's actions but does not address the underlying motivation for their behavior.

The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation?

  • A. Hypothyroidism.
  • B. Thyroid cyst.
  • C. Thyroid cancer.
  • D. Hyperthyroidism.
Correct Answer: D

Rationale: The presence of a bruit over the thyroid indicates increased blood flow, characteristic of hyperthyroidism. This excess blood flow is due to the hypermetabolic state in hyperthyroidism, leading to turbulent blood flow and the audible bruit. A bruit is not typically associated with hypothyroidism, thyroid cysts, or thyroid cancer, as these conditions do not cause increased blood flow. Therefore, the correct interpretation is hyperthyroidism.

The nurse is preparing to obtain a right atrial pressure (RA P/CVP) reading. What are the most appropriate nursing actions? (Select all that apply.)

  • A. Compare measured pressures with other physiological parameters.
  • B. Flush the central venous catheter with 20 mL of sterile saline.
  • C. Inflate the balloon with 3 mL of air and record the pres sure tracing.
  • D. Obtain the right atrial pressure measurement during en d exhalation.
Correct Answer: A

Rationale: The correct answer is A because comparing measured pressures with other physiological parameters ensures accuracy and consistency. This step helps in interpreting the RA P/CVP reading correctly. Choice B is incorrect as flushing the catheter with saline is not necessary for obtaining the pressure reading. Choice C is incorrect as inflating the balloon with air is not part of the correct procedure. Choice D is incorrect because obtaining the measurement during exhalation can affect the accuracy of the reading.

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