Critical care nclex QUESTIONS AND ANSWERS RATED A+

Critical care nclex QUESTIONS AND ANSWERS RATED A+Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply. 1. Administered 9:00 AM medication at 9:30 AM 2. Developed worsening cellulitis after missing antibiotics for 1 day 3. Has a seizure and a history of epilepsy 4. Slides off the edge of the bed and ends up sitting on the floor 5. Waits 4 hours to be transported for STAT diagnostic CT scan 2,4,5 In the intensive care unit, the nurse cares for a client who is being treated for hypotension with a continuous infusion of dopamine. Which assessment finding indicates that the infusion rate may need to be adjusted for the client? 1. Central venous pressure (CVP) is 6 mm Hg 2. Heart rate is 120 beats per minute (bpm) 3. Mean arterial pressure (MAP) is 78 mm Hg 4. Systemic vascular resistance (SVR) is 900 dynes/sec/cm-5 2 Upon arrival in the post-anesthesia care unit (PACU), the nurse performs the initial assessment of a client who had surgery under general anesthesia. Which assessment finding prompts the nurse to notify the health care provider (HCP) immediately? 1. Difficult to arouse 2. Muscle stiffness 3. Pinpoint pupils 4. Temperature 96 F (35.6 C) 2 A client with blunt trauma undergoes an exploratory laparotomy to repair the intraabdominal injury. After 24 hours, the client has a nasogastric tube attached to continual low suction, 2 Hemovac closed-wound suction abdominal drains, and is receiving IV Ringer's lactate and continual epidural morphine. The client now develops hypotension, tachycardia, oliguria, and severe nausea. What is the client's priority nursing diagnosis (ND) at this time? 1. Deficient fluid volume 2. Impaired urinary elimination 3. Nausea 4. Risk for infection 1 The emergency department nurse is assessing a client who was involved in a motor vehicle accident during which the client's head was hit. The client reports neck pain. Which actions are essential for the nurse to perform at this time? Select all that apply. 1. Apply a hard cervical collar 2. Assess neck range of motion 3. Determine if client has rectal tone 4. Position client on firm surface 5. Use logrolling if moving the client 1,4,5 The nurse is caring for a client who had a near-drowning accident in cold weather. Which assessment finding indicates the most severe injury? 1. Decreased body temperature 2. Toes pointed straight down 3. Weak and thready pulse 4. Wheezing on auscultation 2 The nurse in the intensive care unit is caring for a client who is postoperative from a cardiac surgery. The client has a mediastinal chest tube. During assessment, the nurse notes bubbling in the suction control chamber. Which nursing action is appropriate'? 1. Assess the insertion site for presence of subcutaneous emphysema 2. Notify the surgeon of a large air leak 3. Take no action as the chest tube is functioning appropriately 4. Turn down the wall suction until the bubbling disappears 3 The nurse notes a change in the condition of a client in septic shock with an infected leg ulcer and positive blood cultures for methicillin-resistant Staphylococcus aureus. Which assessment finding is most important for the nurse to report to the health care provider? 1. Cold and clammy skin 2. Oxygen saturation of 92% 3. Sinus tachycardia of 118/min 4. Urine output of 0.5 mL/kg/hr 1 There has been a major disaster with the collapse of a large building. Hundreds of victims are expected. The emergency department nurse is sent to triage victims. Which client should the nurse tag "red" and send to the hospital first? 1. Client at 8 weeks gestation with spotting; pulse of 90/min 2. Client with bone piercing skin on leg with oozing laceration; pulse of 88/min 3. Client with fixed and dilated pupils and no spontaneous respirations 4. Client with see-saw chest movement with respirations 4 The nurse is caring for a client who is 1 day postoperative extensive abdominal surgery for ovarian cancer. The client is receiving IV Ringer's lactate at 100 mL/hr and continual epidural morphine for pain control. The Foley catheter urine output has decreased to <20 mLhr over the past 2 hours. The postoperative hematocrit is 36% (0.36), and the hemoglobin is 12 gIdL (120 g/L). Which action should the nurse carry out first? 1. Assess vital signs 2. Increase the IV rate to 125 ml/hr 3. Notify the health care provider 4. Perform a bladder scan 1 An unrestrained, intoxicated client accidentally drives into a steel post by the hospital emergency department door. The client's head hits the windshield, splintering the glass, and the client loses consciousness. What action is a priority for the emergency department nurse? 1. Assess client for a carotid pulse 2. Open client's airway with a head tilt, chin lift maneuver 3. Place hard cervical collar on client 4. Remove client from car onto a backboard 3 A nurse in the intensive care unit (ICU) is caring for a client with sepsis who is on a mechanical ventilator (MV). The client is exposed to the noise of the MV, monitoring equipment, and infusion pump alarms during the day and night. What should the nurse identify as the priority nursing diagnosis (ND)? 1. Anxiety 2. Disturbed sleep pattern 3. Powerlessness 4. Risk for acute confusion 2 Based on the progress note documentation, which priority intervention does the nurse anticipate? Click on the exhibit button for additional information. Exhibit Progress notes 2000 Client admitted to CCU #4, reporting vise-like chest pain and shortness of breath. Pulmonary artery (PA) catheter inserted by the health care provider via right internal jugular vein without difficulty. Central venous pressure (CVP) 18 mm Hg, pulmonary artery wedge pressure (PAWP) 25 mm Hg and coarse crackles auscultated bilaterally. ______________, RN 1. 0.9% sodium chloride, 500 mL intravenous bolus 2. Furosemide, 40 mg intravenous push 3. Metoprolol, 5 mg intravenous push 4. Vancomycin, 1 g intravenously every 12 hours 2 Four clients were involved in a major highway motor vehicle accident. Which client requires priority care? 1. Client with blood pressure of 90/70 mm Hg and deviated trachea 2. Client with concussion who was unconscious for 5 minutes 3. Client with grossly swollen upper thigh and blood pressure of 80/60 mm Hg 4. Client with pain at the thoracic spine and complete paralysis of both legs 1