Critical Care Nursing Questions

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The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the healthcare provider immediately if the patient develops:

  • A. Oxygen saturation of 93%.
  • B. Respirations of 20 breaths/minute.
  • C. Green nasogastric tube drainage.
  • D. Increased jugular venous distention.
Correct Answer: D

Rationale: The correct answer is D: Increased jugular venous distention. In a patient with a subarachnoid hemorrhage and on mechanical ventilation, increased jugular venous distention can indicate increased intracranial pressure, which can be life-threatening. The nurse should notify the healthcare provider immediately as it may require urgent intervention to prevent further neurological deterioration.

A: Oxygen saturation of 93% is within the acceptable range for a patient on mechanical ventilation and may not require immediate notification.
B: Respirations of 20 breaths/minute are within normal limits for a ventilated patient and do not necessarily indicate a critical condition.
C: Green nasogastric tube drainage may indicate the presence of bile and could be related to gastrointestinal issues, but it does not pose an immediate threat to the patient's neurological status.

You may also like to solve these questions

What is the most common cause of a pulmonary embolus?

  • A. An amniotic fluid embolus.
  • B. A deep vein thrombosis from lower extremities.
  • C. A fat embolus from a long bone fracture.
  • D. Vegetation that dislodges from an infected central venous catheter.
Correct Answer: B

Rationale: The correct answer is B: A deep vein thrombosis from lower extremities. Deep vein thrombosis (DVT) is the most common cause of a pulmonary embolus as a blood clot can dislodge from the veins, travel to the lungs, and block blood flow. An amniotic fluid embolus (Choice A) occurs during childbirth and is rare as a cause of pulmonary embolism. A fat embolus (Choice C) typically occurs after a long bone fracture and is more likely to cause issues in the lungs. Vegetation from an infected central venous catheter (Choice D) can cause septic pulmonary embolism, but it is not as common as DVT.

A patients family is exhibiting increasingly impaired coping as the patients condition deteriorates. The nurse asks the family to state the biggest concern from their perspective.What is the most important rationale for this question?

  • A. The question indicates active listening on the part of the nurse.
  • B. The question is used as a way to validate the familys knowledge.
  • C. The question clarifies the nurses understanding of current family needs.
  • D. The question promotes problem definition, which helps define the degree of family understanding.
Correct Answer: C

Rationale: The correct answer is C because asking the family to state their biggest concern clarifies the nurse's understanding of the current family needs. This step allows the nurse to assess the specific areas where the family may require support or assistance, leading to more tailored interventions. By identifying the primary concern, the nurse can better address the family's emotional, informational, or practical needs.

Choice A is incorrect because the question is not solely about active listening; it serves a deeper purpose of assessment. Choice B is incorrect as the question goes beyond validating knowledge to understanding emotional and practical needs. Choice D is incorrect because the question focuses on identifying concerns rather than defining the degree of understanding.

What risk is the rationale for the recommendation of endot racheal rather than nasotracheal intubation?

  • A. Basilar skull fracture
  • B. Cervical hyperextension
  • C. Impaired ability to "mouth" words
  • D. Sinusitis and infection
Correct Answer: A

Rationale: The correct answer is A: Basilar skull fracture. Endotracheal intubation is recommended over nasotracheal intubation to avoid the risk of further damaging a basilar skull fracture. Nasotracheal intubation can potentially cause further injury due to the passage of the tube through the nasal cavity, which could exacerbate a basilar skull fracture.

Summary of other choices:
B: Cervical hyperextension - Not directly related to the choice between endotracheal and nasotracheal intubation.
C: Impaired ability to "mouth" words - Not a significant factor in determining the choice of intubation method.
D: Sinusitis and infection - While nasotracheal intubation can potentially lead to sinusitis and infection, the primary concern in this scenario is the risk of aggravating a basilar skull fracture.

Which of the following are components of the Institute for Healthcare Improvement’s (IHI’s) ventilator bundle? (Select all that apply.)

  • A. Interrupt sedation each day to assess readiness to extub aa bit re b.. c om/test
  • B. Maintain head of bed at least 30 degrees elevation.
  • C. Provide deep vein thrombosis prophylaxis.
  • D. Provide prophylaxis for peptic ulcer disease.
Correct Answer: A

Rationale: The correct answer is A because interrupting sedation daily to assess readiness to extubate is a key component of IHI's ventilator bundle to prevent ventilator-associated pneumonia. This practice helps prevent over-sedation, reduce the duration of mechanical ventilation, and decrease the risk of complications. The other choices, B, C, and D, are incorrect as they are not specific components of the IHI's ventilator bundle. Maintaining head of bed elevation, providing deep vein thrombosis prophylaxis, and prophylaxis for peptic ulcer disease are important aspects of critical care but are not directly related to the ventilator bundle protocol outlined by IHI.

The nurse is caring for a critically ill patient with a very concerned family. Given that the family is under high stress, what nursing intervention will best ameliorate their stress while preserving independence?

  • A. Encourage the family to participate in patient care tasks.
  • B. Teach the family to ask questions of the health care team.
  • C. Ask the family to select a family representative for communication.
  • D. Limit visits to immediate family members for limited times.
Correct Answer: A

Rationale: The correct answer is A: Encourage the family to participate in patient care tasks. This intervention helps to alleviate stress by involving the family in care, promoting a sense of control and empowerment. It also fosters a collaborative relationship between the family and healthcare team. The other choices are incorrect because B only focuses on asking questions but doesn't actively involve the family in care. C may add pressure on the selected representative and exclude others. D limits family involvement and may increase stress by restricting visitation.

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