Critical Care Nursing NCLEX Questions

Critical Care Nursing NCLEX Questions Related

Review Critical Care Nursing NCLEX Questions related questions and content

What is the most important nursing intervention for patien ts who receive neuromuscular blocking agents?

  • A. Administer sedatives in conjunction with the neuromu as bc iu rbl .a cor m b /tl eo sc t king agents.
  • B. Assess neurological status every 30 minutes.
  • C. Avoid interaction with the patient, because he or she won’t be able to hear.
  • D. Restrain the patient to avoid self-extubation.
Correct Answer: B

Rationale: The correct answer is B: Assess neurological status every 30 minutes. This intervention is crucial for patients receiving neuromuscular blocking agents to monitor for any adverse effects such as respiratory depression or paralysis. Regular assessments help ensure early detection of complications and prompt intervention.

A: Administering sedatives in conjunction with neuromuscular blocking agents can potentiate respiratory depression and lead to respiratory compromise.
C: Avoiding interaction with the patient is not appropriate as communication and patient interaction are important aspects of nursing care.
D: Restraint should be avoided as it can increase the risk of complications such as pressure ulcers, anxiety, and decreased respiratory function.

Overall, regular neurological assessments are essential for ensuring patient safety and prompt intervention in case of any complications.

You may also like to solve these questions

In assessing a patient, the nurse understands that what sym ptomology is an early sign of hypoxemia?

  • A. Clubbing of nail beds
  • B. Cyanosis
  • C. Hypotension
  • D. Restlessness
Correct Answer: D

Rationale: Step 1: Restlessness is an early sign of hypoxemia due to the body's response to low oxygen levels.
Step 2: Restlessness occurs as the body tries to increase oxygen intake.
Step 3: Other choices are incorrect because clubbing and cyanosis are late signs, while hypotension is not a specific early sign of hypoxemia.

A PaCO 2 of 48 mm Hg is associated with what outcome?

  • A. Hyperventilation
  • B. Hypoventilation
  • C. Increased absorption of O
  • D. Increased excretion of HCO
Correct Answer: B

Rationale: The correct answer is B: Hypoventilation. A PaCO2 of 48 mm Hg indicates an elevated level of carbon dioxide in the blood, which is typically seen in hypoventilation where the lungs are not effectively removing CO2. Hypoventilation leads to respiratory acidosis. Option A is incorrect because hyperventilation would decrease PaCO2 levels. Option C is incorrect as it does not directly relate to PaCO2 levels. Option D is incorrect as increased excretion of HCO3- would not directly affect PaCO2 levels.

The nurse is caring for four patients on the progressive car e unit. Which patient is at greatest risk for developing delirium?

  • A. 36-year-old recovering from a motor vehicle crash with an alcohol withdrawal protocol.
  • B. 54-year-old postoperative aortic aneurysm resection with an elevated creatinine level
  • C. 86-year-old from nursing home, postoperative from coalboirnb .croemse/tecstti on
  • D. 95-year-old with community-acquired pneumonia; fam ily has brought in eyeglasses and hearing aid
Correct Answer: C

Rationale: The correct answer is C, the 86-year-old postoperative from colonic resection. This patient is at the greatest risk for delirium due to being elderly, having undergone surgery, and having a history of being from a nursing home. These factors contribute to an increased susceptibility to delirium.

A: The 36-year-old with alcohol withdrawal may be at risk for delirium tremens, but the older age of the patient in choice C places them at higher risk.
B: The 54-year-old with an elevated creatinine level postoperative is at risk for complications, but age and history of nursing home placement increase the risk for delirium in choice C.
D: The 95-year-old with community-acquired pneumonia is at risk for delirium, but the combination of age, surgery, and nursing home history in choice C presents a greater risk.

The nurse is assessing the critically ill patient for delirium . The nurse recognizes which characteristics that indicate hyperactive delirium? (Select aabllir bt.hcaomt /atepstp ly.)

  • A. Agitation
  • B. Apathy
  • C. Biting
  • D. Hitting
Correct Answer: A

Rationale: The correct answer is A: Agitation. In hyperactive delirium, patients often exhibit restlessness, agitation, and hyperactivity. This behavior is a key characteristic indicating hyperactive delirium. Apathy (B), biting (C), and hitting (D) are not typically associated with hyperactive delirium. Apathy may be seen in hypoactive delirium, while biting and hitting are not specific indicators of delirium subtypes. Therefore, the correct choice is A as it aligns with the typical presentation of hyperactive delirium.

The patient has elevated blood urea nitrogen (BUN) and serum creatinine levels with a normal BUN/creatinine ratio. These levels most likely indicate

  • A. increased nitrogen intake.
  • B. acute kidney injury, such as acute tubular necrosis (ATN).
  • C. hypovolemia.
  • D. fluid resuscitation.
Correct Answer: B

Rationale: The elevated BUN and creatinine levels with a normal BUN/creatinine ratio indicate impaired kidney function. This pattern is commonly seen in acute kidney injury, such as acute tubular necrosis (ATN). In ATN, there is damage to the renal tubules leading to decreased excretion of waste products, resulting in elevated BUN and creatinine levels. The normal BUN/creatinine ratio suggests that the impairment is due to renal tubular dysfunction rather than prerenal causes like hypovolemia or postrenal causes like urinary obstruction. Increased nitrogen intake would not produce this specific pattern of results. Fluid resuscitation would likely result in dilution of BUN and creatinine levels, leading to lower values.

Copyright © 2025 Nokea. All rights reserved.