Critical Care Nursing Exam Questions

Critical Care Nursing Exam Questions Related

Review Critical Care Nursing Exam Questions related questions and content

The nurse caring for a patient with an endotracheal tube un derstands that endotracheal suctioning is needed to facilitate removal of secretions. What additional information is the nurse aware of concerning this intervention?

  • A. It decreases intracranial pressure.
  • B. It depresses the cough reflex.
  • C. It is done as indicated by patient assessment.
  • D. It is more effective if preceded by saline instillation to loosen secretions.
Correct Answer: C

Rationale: Rationale for Correct Answer C: Endotracheal suctioning should be done as indicated by patient assessment because not all patients require routine suctioning. Performing unnecessary suctioning can lead to potential complications such as mucosal damage and increased risk of infection. Therefore, the nurse must assess the patient's respiratory status, auscultate lung sounds, monitor oxygen saturation levels, and observe for signs of increased secretions before deciding to perform suctioning.

Summary of Incorrect Choices:
A: Endotracheal suctioning does not directly impact intracranial pressure. It is primarily focused on maintaining airway patency and removing respiratory secretions.
B: While endotracheal suctioning may temporarily suppress the cough reflex during the procedure, its primary purpose is to clear airway secretions to prevent complications such as atelectasis and respiratory distress.
D: Saline instillation before suctioning is not recommended as it can lead to negative outcomes such as dehydration, mucosal damage, and increased risk of infection

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What is an early signs of the effect of hypoxemia on the nervous system?

  • A. Cyanosis
  • B. Restlessness
  • C. Tachycardia
  • D. Tachypnea
Correct Answer: B

Rationale: The correct answer is B: Restlessness. When the body experiences hypoxemia (low oxygen levels), the brain is deprived of oxygen, leading to early signs such as restlessness. This is due to the brain's attempt to increase oxygen intake by increasing activity. Cyanosis (A) is a late sign of hypoxemia when oxygen levels are critically low. Tachycardia (C) and tachypnea (D) are compensatory mechanisms in response to hypoxemia, but they are not early signs affecting the nervous system directly.

A family member tells the nurse, 'I don’t know how I’m going to manage without my mother. She took care of everything for us.' Which response by the nurse is most appropriate?

  • A. You will learn how to manage things gradually, and I can provide some resources to help you.
  • B. It will be difficult at first, but time will help you adjust to her loss.
  • C. Perhaps another family member can take over the responsibilities your mother managed.
  • D. It sounds like you will need to seek professional counseling to cope with this loss.
Correct Answer: A

Rationale: The correct answer is A because it acknowledges the family member's feelings while offering support and resources for managing the situation gradually. By providing resources, the nurse empowers the family member to learn how to handle things independently over time. This approach promotes self-reliance and resilience.

Choice B focuses on time rather than active coping strategies, which may not address the family member's immediate needs. Choice C suggests shifting responsibilities to another family member without considering the emotional impact. Choice D jumps to the conclusion of needing professional counseling without exploring other potential solutions or support systems.

A patient is experiencing severe pain, despite receiving pain medication for the past 24 hours. The patients wife expresses concern about this to the nurse. Which response by the nurse would be most empowering to the patients family?

  • A. Explain that the doctor is an expert on pain medication and that the current level ofm edication is the best.
  • B. Recommend that the family members take turns massaging the patients feet todistract from the pain.
  • C. Encourage the family to request that the physician evaluate the patients pain control.
  • D. Ask the family to wait another 24 hours to see whether the patients pain level will go down.
Correct Answer: C

Rationale: The correct answer is C because it empowers the family to take action by requesting a physician evaluation of the patient's pain control. This step is crucial in ensuring that the patient's pain is adequately managed. By involving the physician, the family can advocate for the patient's needs and potentially explore alternative pain management strategies.

Choice A is incorrect because it dismisses the family's concerns and fails to address the need for further evaluation. Choice B may provide temporary relief but does not address the underlying issue of inadequate pain control. Choice D is incorrect as it suggests delaying action, which could lead to prolonged suffering for the patient.

What strategies are appropriate for preventing deep vein tharboirbm.cbomo/steisst (DVT) and pulmonary embolus (PE) in an at-risk patient? (Select all that apply.) WWW .THENURSINGMASTERY.COM

  • A. Graduated compression stockings
  • B. Heparin or low–molecular weight heparin
  • C. Sequential compression devices
  • D. Strict bed rest
Correct Answer: A

Rationale: The correct answer is A: Graduated compression stockings. These stockings help prevent blood from pooling in the legs, reducing the risk of DVT and PE. They improve circulation and reduce venous stasis. Option B, heparin, is used for treatment, not prevention. Option C, sequential compression devices, help prevent DVT but are not as effective as compression stockings. Option D, strict bed rest, can actually increase the risk of DVT by reducing blood flow.

The nurse is caring for a mechanically ventilated patient w ith a pulmonary artery catheter who is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action?a birb.com/test

  • A. Do not document hemodynamic values until the patient can be placed in the supine position.
  • B. Level and zero reference the air-fluid interface of the t ransducer with the patient in the supine position and record hemodynamic values.
  • C. Level and zero reference the air-fluid interface of the t ransducer with the patient’s head of bed elevated to 30 degrees and record hemodynamic values.
  • D. Level and zero reference the air-fluid interface of the tarbainrbs.cdoumc/teers t with the patient supine in the side-lying position and record hemodynamic values.
Correct Answer: C

Rationale: Rationale: Option C is the correct answer because when caring for a patient with a pulmonary artery catheter receiving continuous enteral feedings, it is crucial to level and zero reference the transducer with the patient's head of bed elevated to 30 degrees. This position helps to ensure accurate hemodynamic measurements, as the head of bed elevation minimizes the impact of intra-abdominal pressure on the catheter readings. By referencing the transducer in this position, the nurse can obtain reliable and precise hemodynamic values.

Summary of Incorrect Choices:
A: This option is incorrect because delaying documentation until the patient is in the supine position can lead to inaccuracies in the hemodynamic readings due to changes in patient positioning.
B: Leveling and zero referencing the transducer with the patient in the supine position is not ideal as it does not account for the impact of intra-abdominal pressure on the catheter readings in patients receiving enteral feedings.
D: Leveling and zero referencing

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