Critical Care Nursing Questions and Answers with Rationale

Critical Care Nursing Questions and Answers Part 1

1) A nurse has developed a nursing diagnosis of ineffective airway clearance for a client who sustained an inhalation burn injury. Which of the following nursing intervention should include in the plan of care for this client?

a. Monitor oxygen saturation every 4 hrs.
b. Encourage coughing and deep breathing every 4 hrs.
c. Elevate the head of bed
d. Asses respiratory rate and breath sounds every 4 hrs.

2) A client who is involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates which intravenous solution will most likely be prescribed to increase intravascular volume, replace immediate blood loss and increase blood pressure?

a. 5%D in lactated Ringer’s solution
b. 0.33%normal saline
c. 0.225%normal saline
d. 0.45%normal saline

3) A nurse in the telemetry unit is monitoring a client for cardiac changes indicative of hypokalemia. Which of the following if noted in cardiac monitor, would indicate the presence of hypokalemia?
a. Tall, peaked T wave
b. ST segment depression
c. Widening QRS complex
d. Prolonged PR interval

4) A nurse is performing cardiopulmonary resuscitation (CPR)on a client who has had a cardiac arrest. An automatic external defibrillator is available to treat the client. Which of the following activities will allow the nurse to assess the client’s cardiac rhythm?
a. Hold the defibrillator paddles firmly against the chest
b. Apply adhesive patch electrodes to the chest and move away from the client
c. Apply standard ECG monitoring leads to the client and observe the rhythm
d. Connect standard ECG electrodes to a trans telephonic monitor

5) A client who sustained an inhalation injury arrives in ER. On initial assessment the nurse notes that the client is very confused and combative. The nurse determines that the client is most likely experiencing?
a. Anxiety
b. Fear
c. Pain
d. Hypoxia

6) A nurse attempts to relieve an airway obstruction on a 3year old conscious child. The nurse performs this maneuver correctly by standing behind the child, placing her arms under the client’s axillae and around the client and positioning her hands to deliver thrusts between.
a. Groin and the abdomen
b. Umbilicus and the groin
c. Lower abdomen and the chest
d. Umbilicus and the xiphoid process

7) The ER nurse is monitoring a client who received treatment for a severe asthma attack. The nurse determines that the client’s respiratory status had worsened if which of the following is noted on assessment?
a. Diminished breath sounds
b. Wheezing during inhalation
c. Wheezing during exhalation
d. Wheezing throughout the lung fields

8)The nurse is performing CPR on a 7year old child. The nurse delivers how many breaths per minute the child?
a. 6
b. 8
c. 10
d. 20

9) A client in cardiogenic shock has a pulmonary artery catheter (Swan-Ganz type) placed. The nurse would interpret which of the following cardiac output (CO)and pulmonary capillary wedge pressure (PCWP) readings as indicating that the client is most unstable?

a. CO 5l/min PCWP low
b. CO 2l/min PCWP low
c. CO 4l/min PCWP high
d. CO 3l/min PCWP high

10)A client is undergoing fluid replacement after burned on 20% of her body 12 hr. ago. The nursing assessment reveals a Blood pressure of 90/50mmHg, Pulse rate of 110b/t, and urine output of 20ml/hr. The nurse reports the findings to the physician and anticipates which of the following prescriptions?

a. Transfusing One packed red blood cells
b. Administering a diuretic to increase the urine output
c. Increasing the amount of IV Lactated Ringer’s solution
d. Changing the IV lactated Ringer’s solution to dextrose in water

11) A nurse is performing an assessment on a client who was admitted to the hospital with a diagnosis of carbon monoxide poisoning. Which of the following assessments performed by the nurse would primarily elicit data related to a deterioration of the client’s condition?

a. Skin color
b. Apical rate
c. Respiratory rate
d. Level of consciousness

12)A nurse suspects that a pulmonary embolism has developed in a postpartum client with femoral thrombophlebitis. The immediate nursing action would be to:

a. Monitor vital signs
b. Elevate the head of the bed 30 to 40degrees
c. Initiate an intravenous line if one is not already in place
d. Administer oxygen by face mask as prescribed at 8-10l/min

13)A nurse is planning care for a client with intracranial pressure (ICP) monitoring. Which of the following interventions would be contraindicated in the plan of care?

a. Using strict aseptic technique when touching the monitoring system
b. Assessing the insertion site for signs and symptoms of infection
c. Leveling the transducer at the lowest point of the ear
d. Checking all stopcocks and connections for leaks

14) A client with a history of silicosis is admitted to the hospital with respiratory distress and impending respiratory failure. The nurse plans to have which of the following items readily available at the client’s bedside?

a. Chest tube drainage system
b. Intubation tray
c. Thoracentesis tray
d. Crash cart

15) A client in shock is receiving dopamine hydrochloride by intravenous infusion. The nurse should have which of the following medications available for local injection if IV infiltration and medication extravasation occur?

a. Vitamin K
b. Phentolamine
c. Atropine sulphate
d. Protamine sulphate

Obstetrics and Gynecology Nursing Questions and Answers

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