Critical Care Nursing Practice Questions

Critical Care Nursing Practice Questions Related

Review Critical Care Nursing Practice Questions related questions and content

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?

  • A. Verbalize understanding of plan and of intention to eat meals.
  • B. Eat 50% of six small meals each day by the end of one week.
  • C. Meals prepared during hospitalization will be fed by the nurse.
  • D. Demonstrate progressive weight gain toward the ideal weight.
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.

You may also like to solve these questions

The nurse is caring for a patient diagnosed with hyperactivaebi rdb.ecloimri/tuemst . The nurse focuses interventions toward which priority need?

  • A. Comfort
  • B. Nourishment
  • C. Safety
  • D. Sedation
Correct Answer: C

Rationale: The correct answer is C: Safety. In hyperactive delirium, the patient may be agitated, disoriented, and at risk of harm. Safety is the priority to prevent falls or injury. Comfort (A) is important but secondary to safety in this case. Nourishment (B) can wait until safety is ensured. Sedation (D) may be considered but only after safety measures are in place.

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

  • A. Tooth brushing is performed every 2 hours for the greatest effect.
  • B. Implementing a comprehensive oral care program is an intervention for preventing WWW .THENURSINGMASTERY.COM VAP.
  • C. Oral care protocols should include oral suctioning and brushing teeth.
  • D. Protocols that include chlorhexidine gluconate have beaebnirb e.cfofme/ctetsivt e in preventing VAP.
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.

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?

  • A. Activate the rapid response system.
  • B. Place the patient in Trendelenburg position.
  • C. Assess the cuff for proper arm size.
  • D. Administer 0.9% normal saline bolus.
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.

An ICU nurse has provided excellent care for a 6-year-old girl who had been admitted to the ICU for a head injury. The nurse was attentive not only to the needs of the patient but also went out of her way to care for the needs of the girls family. According to research, which of the following forms of recognition would the nurse value the most?

  • A. A card from the girls family
  • B. A plaque from the ICU physicians naming her as Nurse of the Year
  • C. A letter of commendation from the hospitals administration
  • D. A bouquet of flowers from her supervisor
Correct Answer: A

Rationale: Rationale: The correct answer is A: A card from the girl's family. The nurse would value this form of recognition the most because it directly reflects the impact of her care on the patient and her family. It is a personal, heartfelt gesture that acknowledges the nurse's compassion and dedication. A card from the family shows genuine appreciation and gratitude for the nurse's efforts, making it the most meaningful form of recognition.

Summary:
- Choice B: A plaque from the ICU physicians could be seen as a formal recognition but lacks the personal touch and direct impact of the nurse's care on the patient and family.
- Choice C: A letter of commendation from the hospital's administration is a professional acknowledgment but may not capture the emotional connection and impact that the nurse had on the family.
- Choice D: A bouquet of flowers from her supervisor is a nice gesture but does not necessarily reflect the specific impact of the nurse's care on the patient and family.

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?

  • A. The endotracheal tube is in the right mainstem bronchus.
  • B. The patient has a left pneumothorax.
  • C. The patient has aspirated secretions during the proceduarbeir.b .com/test
  • D. The stethoscope earpiece is clogged with wax.
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.

Copyright © 2025 Nokea. All rights reserved.