NCLEX Critical Care Nurse Question

1. 1.The critical care nurse recognizes that an ideal plan for caregiver involvement includes A. allowing caregivers at the bedside at preset, brief intervals. B. a caregiver at the bedside at all times. C. restriction of visiting in the ICU because the environment is overwhelming to caregivers. D. an individually devised plan to involve caregivers with care and comfort measures. (Answer)D. An individually devised plan to involve caregivers with care and comfort measures. 2. Rationale: An individualized plan of care should be developed for each patient and the caregivers. Caregivers should be allowed to assist with care and comfort measures in the ICU if desired. 3. A client receiving a transfusion of packed red blood cells begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8 ° F orally from a baseline of 99.2 ° F. The nurse determines that the client may be experiencing which complication of a blood transfusion? A. Septicemia B. Hyperkalemia C. Circulatory overload D. Delayed transfusion reaction (Answer)A. Septicemia 4. occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. 5. The intensive care unit (ICU) nurse educator will determine that teaching about arterial pressure monitoring for a new staff nurse has been effective when the nurse a. balances and calibrates the monitoring equipment every 2 hours. b. positions the zero-reference stopcock line level with the phlebostatic axis. c. ensures that the patient is supine with the head of the bed flat for all readings. d. rechecks the location of the phlebostatic axis when changing the patient's position. (Answer)B positions the zero-reference stopcock line level with the phlebostatic axis. 6. Rationale: For accurate measurement of pressures, the zero-reference level should be at the phlebostatic axis. There is no need to rebalance and recalibrate monitoring equipment hourly. Accurate hemodynamic readings are possible with the patient's head raised to 45 degrees or in the prone position. The anatomic position of the phlebostatic axis does not change when patients are repositioned. 7. The nurse wants to assess the oxygenation status of a patient who has been experiencing a gastrointestinal bleed. How will the nurse complete this assessment? Select all that apply. A. Use pulse oximetry B. Send a blood sample for arterial blood gas analysis C. Auscultate lung sounds D. Evaluate cardiac rhythm strip E. Calculate mean arterial pressure (Answer)A. Use pulse oximetry B. Send a blood sample for arterial blood gas analysis 8. What are appropriate nursing interventions for the patient with delirium in the ICU? (Select all that apply) A. Use clocks and calendars to maintain orientation. B. Encourage round-the-clock presence of caregivers at the bedside. C. Sedate the patient with appropriate drugs to protect the patient from harmful behaviors. D. Silence all alarms, reduce overhead paging, and avoid conversations around the patient. E. Identify physiological factors that may be contributing to the patient's confusion and irritability. (Answer)A,C,E 9. The use of clocks and calendars can help orient the patient with delirium in the intensive care unit (ICU). If the patient demonstrates hyperactivity, insomnia, or delusions, management with neuroleptic drugs (e.g., haloperidol [Haldol]) can be considered. Physical conditions such as hemodynamic instability, hypoxemia, hypercarbia, electrolyte disturbances, and severe infections can precipitate delirium.