Critical Care Nursing NCLEX Questions

Critical Care Nursing NCLEX Questions Related

Review Critical Care Nursing NCLEX Questions related questions and content

The nurse observes that an elderly woman, whose granddaughter has been admitted to theICU, is struggling to manage her two great-grandsons, who are toddlers, in the waiting room. What is the most likely explanation for the womans inability to manage the children in this situation?

  • A. She is senile.
  • B. She is in the exhaustion stage of the general adaptation syndrome to stress.
  • C. She is assuming the role of caregiver in place of the patient, a role she is not used to.
  • D. She has macular degeneration and cannot see well.
Correct Answer: B

Rationale: The correct answer is B: She is in the exhaustion stage of the general adaptation syndrome to stress.

Rationale:
1. In the exhaustion stage, the body's resources are depleted due to prolonged stress, leading to fatigue and reduced ability to cope.
2. The elderly woman is likely experiencing high levels of stress due to her granddaughter's critical condition.
3. Managing toddlers while dealing with the emotional distress of a loved one in the ICU can be overwhelming, causing exhaustion.
4. This explanation aligns with the symptoms of fatigue and difficulty managing the children observed by the nurse.

Summary:
A: Incorrect. Senility is a cognitive condition unrelated to the stress of the situation.
C: Incorrect. Assuming a caregiver role can be stressful, but it does not explain the observed exhaustion.
D: Incorrect. Macular degeneration affects vision, not the ability to manage stress and children.

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A nurse in the ICU is responding to a patient who has just gone into cardiac arrest. A moment later, the nurse is notified that another patient has just gone into anaphylactic shock due to a drug allergy. She is conflicted as to what to do, as she is the only nurse available at the moment to tend to both patients. Which component of a healthy work environment is lacking in this scenario?

  • A. Effective decision making
  • B. Appropriate staffing
  • C. Authentic leadership
  • D. Meaningful recognition
Correct Answer: B

Rationale: The correct answer is B: Appropriate staffing. In this scenario, the nurse is conflicted because she is the only nurse available to tend to both critical patients. Appropriate staffing ensures that there are enough healthcare professionals to provide timely and effective care to patients in need. In this situation, the lack of adequate staffing is evident as the nurse is overwhelmed and unable to give proper attention to both patients simultaneously. Effective decision making (choice A) can be hindered by inadequate staffing but is not the primary issue here. Authentic leadership (choice C) and meaningful recognition (choice D) are important components of a healthy work environment but are not directly related to the lack of staffing in this scenario.

After the change-of-shift report, which patient should the progressive care nurse assess first?

  • A. Patient who was extubated in the morning and has a temperature of 101.4°F (38.6°C).
  • B. Patient with bilevel positive airway pressure (BiPAP) for sleep apnea whose respiratory rate is 16.
  • C. Patient with arterial pressure monitoring who is 2 hours post percutaneous coronary intervention and needs to void.
  • D. Patient who is receiving IV heparin for venous thromboembolism and has a partial thromboplastin time (PTT) of 98 seconds.
Correct Answer: D

Rationale: The correct answer is D. The patient receiving IV heparin with a PTT of 98 seconds is at risk for bleeding due to the therapeutic range of 60-80 seconds. Assessing this patient first is crucial to prevent potential bleeding complications. A high PTT indicates the blood is not clotting properly, increasing the risk of bleeding. Prompt assessment and possible adjustment of heparin infusion are needed.

A: The patient with a temperature of 101.4°F may have a fever but is not at immediate risk compared to the patient with a high PTT.
B: The patient on BiPAP with a respiratory rate of 16 is stable and does not require immediate assessment.
C: The patient post-percutaneous coronary intervention needing to void is a routine need and does not require immediate attention compared to the patient with a critical lab value.

Which action is a priority for the nurse to take when the low-pressure alarm sounds for a patient who has an arterial line in the left radial artery?

  • A. Fast flush of the arterial line.
  • B. Check the left hand for pallor.
  • C. Assess for cardiac dysrhythmias.
  • D. Rezero the monitoring equipment.
Correct Answer: C

Rationale: Rationale for Correct Answer (C): When the low-pressure alarm sounds for a patient with an arterial line, the nurse should assess for cardiac dysrhythmias first. This is because a sudden drop in pressure could indicate a serious issue affecting the heart's ability to pump effectively. Identifying and addressing any cardiac dysrhythmias promptly is crucial for patient safety.

Summary of Incorrect Choices:
A: Fast flush of the arterial line - This would not address the underlying cause of the low-pressure alarm and may not be necessary.
B: Check the left hand for pallor - While assessing perfusion is important, it is not the priority when the alarm indicates a potential cardiac issue.
D: Rezero the monitoring equipment - While important for accuracy, it is not the priority when the alarm indicates a potential cardiac concern.

What is a minimally acceptable urine output for a patient weighing 75 kg?

  • A. Less than 30 mL/hour
  • B. 37 mL/hour
  • C. 80 mL/hour
  • D. 150 mL/hour
Correct Answer: C

Rationale: The correct answer is C (80 mL/hour) because the minimum acceptable urine output for a patient is approximately 0.5-1 mL/kg/hour. For a 75 kg patient, this equates to 37.5-75 mL/hour. Therefore, an output of 80 mL/hour is within this range and is considered minimally acceptable.

A: Less than 30 mL/hour is incorrect because it is below the recommended range for a 75 kg patient.
B: 37 mL/hour is close to the lower end of the acceptable range, but it is not the minimum acceptable output.
D: 150 mL/hour is above the recommended range and would be considered excessive for a 75 kg patient.

When rewarming a patient who arrived in the emergency department (ED) with a temperature of 87°F (30.6°C), which assessment indicates that the nurse should discontinue active rewarming?

  • A. The patient begins to shiver.
  • B. The BP decreases to 86/42 mm Hg.
  • C. The patient develops atrial fibrillation.
  • D. The core temperature is 94°F (34.4°C).
Correct Answer: D

Rationale: The correct answer is D. When rewarming a hypothermic patient, the goal is to gradually increase their core temperature. A core temperature of 94°F (34.4°C) is still below the normal range, but it indicates that the rewarming process is working. Shivering (A) is a normal response to rewarming. A decrease in blood pressure (B) may be expected due to peripheral vasodilation during rewarming. Developing atrial fibrillation (C) may be a concern but does not necessarily indicate that rewarming should be discontinued. Therefore, choice D is correct as it signifies progress in the rewarming process.

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