Critical Care Nursing NCLEX Questions

Critical Care Nursing NCLEX Questions Related

Review Critical Care Nursing NCLEX Questions related questions and content

The nurse uses the Situation-Background-Assessment-Recommendation (SBAR) format to communicate a change in patient status to a healthcare provider. In which order should the nurse make the following statements?

  • A. The patient needs to be evaluated immediately and may need intubation and mechanical ventilation.
  • B. The patient was admitted yesterday with heart failure and has been receiving furosemide (Lasix) for diuresis, but urine output has been low.
  • C. The patient has crackles audible throughout the posterior chest and the most recent oxygen saturation is 89%. Her condition is very unstable.
  • D. This is the nurse on the surgical unit. After assessing the patient, I am very concerned about increased shortness of breath over the past hour.
Correct Answer: B

Rationale: Step 1: Start with Background - statement B provides relevant background information about the patient's current condition and why there is a need for communication.
Step 2: Move on to Situation - statement D sets the current situation where the nurse expresses concern about the patient's symptom.
Step 3: Next is Assessment - statement C details the nurse's assessment findings, highlighting the critical aspects of the patient's condition.
Step 4: End with Recommendation - statement A suggests the necessary action to be taken based on the assessment findings. This order ensures a clear and structured communication process.

Summary:
- Choice A is incorrect as the recommendation should come after providing background, situation, and assessment.
- Choice C is incorrect as assessment details should precede the patient's critical condition.
- Choice D is incorrect as the situation should be explained before expressing concern.

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The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse sh ould provide instruction?

  • A. “If you get the pneumococcal vaccine, you’ll never get pneumonia again.”
  • B. “It is important for you to get an annual influenza shot to reduce your risk of pneumonia.”
  • C. “Stay away from cold, drafty places because that incre ases your risk of pneumonia when you get home.”
  • D. “Since you have been treated for pneumonia, you now have immunity from getting it in the future.”
Correct Answer: B

Rationale: Step 1: Influenza can lead to pneumonia as a complication, so getting an annual flu shot can reduce the risk of pneumonia.
Step 2: Providing education on the importance of prevention aligns with discharge teaching goals.
Step 3: Option A is incorrect as the pneumococcal vaccine doesn't guarantee immunity from all causes of pneumonia.
Step 4: Option C is incorrect as cold or drafty places do not directly cause pneumonia.
Step 5: Option D is incorrect as having pneumonia once does not confer permanent immunity.

The nurse is caring for a patient who is orally intubated and on a mechanical ventilator. The nurse believes that the patient is experiencing excess anxiety. For this patient, what behavior best indicates anxiety?

  • A. Restlessness
  • B. Verbalization
  • C. Increased respiratory rate
  • D. Glasgow Coma Scale score of 3
Correct Answer: A

Rationale: The correct answer is A: Restlessness. Restlessness is a common behavioral indicator of anxiety in patients. In this scenario, a patient who is orally intubated and on a ventilator may not be able to verbally express anxiety, making restlessness a more prominent sign. Verbalization may not be possible due to intubation. While increased respiratory rate can be a symptom of anxiety, it is also a common physiological response in patients on mechanical ventilation. A Glasgow Coma Scale score of 3 indicates severe impairment of consciousness, not specifically anxiety.

When providing palliative care, the nurse must keep in mind that the family may include which of the following? (Select all that apply.)

  • A. Unmarried life partners of same sex
  • B. Unmarried life partners of opposite sex
  • C. Roommates
  • D. Close friends
Correct Answer: A

Rationale: The correct answer is A: Unmarried life partners of same sex. When providing palliative care, it's crucial to recognize and respect diverse family structures. Unmarried life partners of the same sex may form a significant familial bond, requiring support and involvement in care decisions. This choice aligns with the principles of inclusivity and non-discrimination in palliative care.

Incorrect choices:
B: Unmarried life partners of the opposite sex - This choice is incorrect as it limits the definition of family to only opposite-sex partners, excluding same-sex couples.
C: Roommates - While roommates may provide support, they do not necessarily have the same level of emotional and decision-making involvement as family members or life partners.
D: Close friends - While close friends can be important sources of support, they do not necessarily have the same legal or emotional ties as a life partner.

A normal glomerular filtration rate is

  • A. less than 80 mL/min.
  • B. 80 to 125 mL/min.
  • C. 125 to 180 mL/min.
  • D. more than 189 mL/min.
Correct Answer: B

Rationale: The correct answer is B (80 to 125 mL/min) because this range reflects the normal glomerular filtration rate (GFR) in adults. GFR measures the rate at which blood is filtered by the kidneys, typically around 125 mL/min. A GFR below 60 mL/min indicates kidney dysfunction, making option A incorrect. Option C (125 to 180 mL/min) is above the normal range. Option D (more than 189 mL/min) is too high and could indicate hyperfiltration, common in conditions like diabetes. Therefore, choice B is the most appropriate within the normal GFR range.

A 75-year-old patient, who suffered a massive stroke 3 weeks ago, has been unresponsive and

  • A. The primary health care provider has approached the spouse regarding placement of a perma nent feeding tube. The spouse states that the patient never wanted to be kept alive by tub es and personally didn’t want what was being done. After holding a family conference with th e spouse, the medical team concurs and the feeding tube is not placed. What term would be used to describe this situation?
  • B. Euthanasia
  • C. Palliative care
  • D. Withdrawal of life support
Correct Answer: E

Rationale: Step 1: The scenario describes a decision made based on the patient's previously expressed wishes.
Step 2: The decision aligns with the principle of respecting patient autonomy.
Step 3: The term that best describes this situation is "Advance Directive."
Summary:
- A: Incorrect, as it involves actively ending the patient's life without their consent.
- B: Incorrect, as euthanasia involves intentionally causing death to relieve suffering.
- C: Incorrect, as palliative care focuses on improving quality of life for the patient.
- D: Incorrect, as withdrawal of life support involves discontinuing medical interventions, not honoring the patient's wishes.

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