Critical Care Nursing NCLEX Questions

Critical Care Nursing NCLEX Questions Related

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As the nurse admits a patient with end-stage kidney disease to the hospital, the patient tells the nurse, 'If my heart or breathing stops, I do not want to be resuscitated.' Which action is best for the nurse to take?

  • A. Ask if these wishes have been discussed with the healthcare provider.
  • B. Place a Do Not Resuscitate (DNR) notation in the patient’s care plan.
  • C. Inform the patient that a notarized advance directive must be included in the record.
  • D. Advise the patient to designate a person to make health care decisions.
Correct Answer: A

Rationale: Step 1: Asking if these wishes have been discussed with the healthcare provider is important to ensure that the patient's wishes are documented and considered in the care plan.
Step 2: The healthcare provider needs to be aware of the patient's preferences regarding resuscitation to provide appropriate care.
Step 3: This step helps in clarifying the patient's preferences and ensures that the healthcare team follows the patient's wishes.
Step 4: Placing a DNR notation without consulting the healthcare provider may not align with the patient's overall care plan and may lead to potential legal and ethical issues.
Step 5: Informing the patient about notarized advance directives and designating a person for healthcare decisions are important but not the immediate step needed in this scenario.
In summary, choice A is correct as it prioritizes communication with the healthcare provider to ensure the patient's wishes are properly documented and followed. Choices B, C, and D are incorrect because they do not involve confirming the patient's wishes

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During a client assessment, the client says, 'I can't walk very well.' Which action should the nurse implement first?

  • A. Predict the likelihood of the outcome.
  • B. Consider alternatives.
  • C. Choose the most successful approach.
  • D. Identify the problem.
Correct Answer: D

Rationale: The correct answer is D: Identify the problem. This is the first action the nurse should take in the nursing process as it helps in understanding the client's issue. By identifying the problem, the nurse can gather more information through further assessment to determine the underlying cause of the client's difficulty in walking. This step is crucial for developing an effective care plan and interventions.

A: Predict the likelihood of the outcome - This choice is not appropriate as predicting the outcome should come after identifying the problem and implementing interventions.

B: Consider alternatives - While considering alternatives is important in the decision-making process, it is not the immediate action needed in this scenario.

C: Choose the most successful approach - This choice is premature as the nurse needs to first identify the problem before determining the most successful approach.

A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse should provide the patient with what explanation?

  • A. “I’m going to contact the pharmacist to see if you can take this medication by mouth.”
  • B. “This injection is being given to prevent blood clots fr om forming.”
  • C. “This medication will dissolve any blood clots you migabhirtb .gcoemt./”te st
  • D. “I will contact your primary care provide to discuss wh y you are getting this medication.” t
Correct Answer: B

Rationale: The correct answer is B: “This injection is being given to prevent blood clots from forming.” Enoxaparin is an anticoagulant used to prevent blood clots. It is administered through injection, not orally (A). Enoxaparin does not dissolve existing blood clots (C). Contacting the primary care provider to discuss the medication is not necessary in this scenario (D). The correct choice emphasizes the purpose of enoxaparin in preventing new blood clots.

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.

The American Association of Critical-Care Nurses (AACN) sponsors certification in critical care nursing for several critical care subspecialties. What is the most important benefit of such certification for the profession of nursing?

  • A. Provides positive publicity for nursing
  • B. Validates nurses expert knowledge and practice
  • C. Mandated by government regulations
  • D. Demonstrates basic knowledge in the field
Correct Answer: B

Rationale: The correct answer is B because certification validates nurses' expert knowledge and practice. This is important as it ensures that nurses have the necessary skills and competence to provide high-quality care in critical care settings. Certification is voluntary and not mandated by government regulations (Choice C). It goes beyond demonstrating basic knowledge (Choice D) by confirming specialized expertise. While certification may garner positive publicity (Choice A), the primary benefit is the validation of advanced skills and knowledge.

Identify which substances in the glomerular filtrate would indicate a problem with renal function. (Select all that apply.)

  • A. Protein
  • B. Sodium
  • C. Creatinine
  • D. Red blood cells
Correct Answer: A

Rationale: The presence of protein in the glomerular filtrate indicates a problem with renal function because in healthy kidneys, proteins are retained in the blood and not filtered into the urine. If protein is found in the filtrate, it suggests damage to the glomerular filtration barrier. Sodium, creatinine, and red blood cells are normally present in the filtrate and are not indicative of renal dysfunction. Sodium is freely filtered and reabsorbed, creatinine is a waste product of muscle metabolism excreted by the kidneys, and a small number of red blood cells may be filtered due to their small size. Therefore, protein in the glomerular filtrate is the most specific indicator of renal dysfunction.

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