NCLEX Critical Care Questions and answers

The nurse is caring for an intubated client whose oxygen saturation begins to drop. What action should the nurse do next? Auscultate lungs sounds bilaterally - need to determine cause before you do something next When caring for a client with a left radial artery catheter, which assessment data obtained by the nurse indicates the need to take immediate action? Patient's left hand is cooler than the right What is an Allen's test? a method of gauging the flow of blood in the hands it's used to determine adequate collateral blood flow in the hand by evaluating the patency of the radial and ulnar arteries - patient makes fist, occlude radial and ulnar arteries, open fist, palm shows pallor, release pressure on ulnar artery, color comes back to hand The nurse is caring for a client on a mechanical ventilator. The settings on the ventilator have just been changed, and the standing prescription is to draw arterial blood gases 30 minutes after a ventilator change. In anticipation of this blood draw, what intervention should the nurse implement? Avoid suctioning the patient The nurse is caring for a client with surgical complications who requires continuous total parenteral nutrition (TPN). The nurse assists the health care provider with the insertion of a subclavian triple lumen central venous access device. What is the nurse's priority action before initiating the TPN infusion? Check results of the chest x-ray What is Guillain-Barré syndrome (GBS)? Guillain-Barré syndrome (GBS) is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle paralysis and absence of reflexes. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves (CNs). What is the life threatening complication of Guillain-Barré syndrome? Respiratory compromise from the paralysis ascending into the thoracic region. - Monitoring for rate/depth of respirations and measuring serial bedside vital capacity (spirometry) help to detect this early in the disease course. The charge nurse is evaluating the skills of a new registered nurse (RN) assigned to care for a client with shock. Which action taken by the new RN indicates a need for further education? Places the patient with sepsis in high fowlers position - this causes BP to decrease What is pulmonary artery wedge pressure? (PAWP) indirect measure of pressure in the left ventricle at the end of diastole - 6-12 A registered nurse is precepting a new nurse in the intensive care unit. The client is sedated with propofol, on a mechanical ventilator, and is receiving enteral feeding via nasogastric tube. The new nurse performs interventions to prevent aspiration. The preceptor should intervene if the new nurse performs which of the following actions? Requests that the doctor change continuous feedings to bolus - bolus feedings are contraindicated in most CC patients due to aspiration risk What is the treatment for stable VT vs. unstable VT (pulse vs. pulseless)? 1) The unstable client in VT with a pulse is treated with synchronized cardioversion. 2) The stable client in VT with a pulse is treated with antiarrhythmic medications (eg, amiodarone, procainamide, sotalol). What are the criteria for calling the rapid response team? Any provider worried about the client's condition OR An acute change in any of the following: Heart rate 40 or 130/min Systolic blood pressure 90 mm Hg Respiratory rate 8 or 28/min (Option 4) Oxygen saturation 90 despite oxygen Urine output 50 mL/4 hr Level of consciousness The nurse is assisting with cardiopulmonary resuscitation of a client in cardiac arrest. The rhythm in the exhibit is displayed on the cardiac monitor. Which medication administration should the nurse anticipate? Magnesium IV - used for torsades de pointes What is torsades de pointes? A polymorphic ventricular tachycardia characterized by QRS complexes that change size and shape in a characteristic twisting pattern. Torsades de pointes is usually due to a prolonged QT interval (more than half the RR interval), which is the result of electrolyte imbalances, especially hypomagnesemia, or some medications. What is adenosine used for? An anti-arrhythmic used to treat supraventricular tachycardia. What is IV dopamine used for? A vasopressor used to treat symptomatic hypotension. What is the rate of compressions for CPR on an adult? 100 - 120 To obtain accurate continuous blood pressure readings via a radial arterial catheter, the nurse places the air-filled interface of the stopcock at the phlebostatic axis. Where is it located? Level of atria at 4th intercostal space, 1/2 anterior - posterior (AP) diameter What is the angle of Louis? The palpable raised notch where the manubrium and sternum are joined. - This anatomical location is useful in counting the ICSs and in finding auscultatory areas. Where is the aortic area located? An auscultatory area located at the 2nd ICS to the right of the sternal border. Where is the mitral area (apex)? An auscultatory area, and the point of maximal impulse are located at the 5th ICS at the MCL. Where is the phlebostatic axis located? The 4th ICS, at the midway point of the AP diameter (½ AP) of the chest wall. The stopcock nearest the transducer is placed here to assure accurate pressure measurements. When is epi given during a code? It is given after compressions and defibrillation An intoxicated client not wearing a seatbelt drives into a metal barricade near the entrance to the emergency department. The client's head has hit the windshield, and the client is unconscious. What nurse actions are appropriate? 1) Assess the patient for a carotid pulse 2) Determine the glasgow coma scale score 3) Maintain airway with jaw thrust maneuver (done in those who may have possible spinal injuries 4) Place hard cervical collar on 5) Move from car and onto backboard A client with hypothermia has just arrived in the emergency department via ambulance. The client is being rewarmed with blankets, and the IV fluids are being changed over to warmed fluids. What additional intervention is a priority? Attaching the cardiac monitor - v-fib can occur from hypothermia, anticipate defibrillation The nurse is caring for a client with sepsis and acute respiratory failure who was intubated and prescribed mechanical ventilation 3 days ago. The nurse assesses for which adverse effect associated with the administration of positive pressure ventilation (PPV)? Hypotension - Positive pressure ventilation causes increased intrathoracic pressure and reduced venous return and cardiac output, which can result in hypotension. Emergency medical service personnel are transporting a near-drowning victim who is currently hypothermic. Based on anticipated vital signs, the nurse needs to prepare for which interventions? Covering patient with warm blankets Mechanical ventilation Warmed IV fluids A client with acute respiratory distress syndrome is receiving positive pressure mechanical ventilation with 15 cm H2O (11 mm Hg) positive end-expiratory pressure (PEEP). The nurse should assess for which complication associated with PEEP? Barotrauma - High PEEP is commonly used to prevent small airway/alveolar collapse in clients with ARDS. PEEP helps to reduce oxygen toxicity. However, high levels of PEEP (10-20 cm H2O [7.4-14.8 mm Hg]) can cause barotrauma to the lung, resulting in a pneumothorax, and decreased venous return causes hypotension.