NCLEX Critical Care Nurse Question
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 - ANSA. Septicemia
occurs with the transfusion of blood contaminated with microorganisms. Signs include chills,
fever, vomiting, diarrhea, hypotension, and the development of shock.
2. 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. -
ANSD. An individually devised plan to involve caregivers with care and comfort measures.
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.
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 - ANSA. Use pulse oximetry
B. Send a blood sample for arterial blood gas analysis
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.
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 - ANSA. Septicemia
occurs with the transfusion of blood contaminated with microorganisms. Signs include chills,
fever, vomiting, diarrhea, hypotension, and the development of shock.
2. 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. -
ANSD. An individually devised plan to involve caregivers with care and comfort measures.
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.
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 - ANSA. Use pulse oximetry
B. Send a blood sample for arterial blood gas analysis
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.
