1. The nurse is caring for an intu- Auscultate lungs sounds bilaterally
bated client whose oxygen sat- - need to determine cause before you do
uration begins to drop. What ac- something next
tion should the nurse do next?
2. When caring for a client with a Patient's left hand is cooler than the right
left radial artery catheter, which
assessment data obtained by the
nurse indicates the need to take
immediate action?
3. What is an Allen's test? a method of gauging the flow of blood
in the hands it's used to determine ade-
quate 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 pal-
lor, release pressure on ulnar artery, color
comes back to hand
4. The nurse is caring for a client on Avoid suctioning the patient
a mechanical ventilator. The set-
tings 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 inter-
vention should the nurse imple-
ment?
5. The nurse is caring for a Check results of the chest x-ray
client with surgical complica-
tions who requires continuous
total parenteral nutrition (TPN).
The nurse assists the health care
provider with the insertion of a
subclavian triple lumen central
, NCLEX Critical Care Questions with 100% Verified Solutions
venous access device. What is
the nurse's priority action before
initiating the TPN infusion?
6. What is Guillain-Barré syndrome Guillain-Barré syndrome (GBS) is an
(GBS)? acute, immune-mediated polyneuropathy
that is most often accompanied by as-
cending muscle paralysis and absence of
reflexes. Lower-extremity weakness pro-
gresses over hours to days to involve the
thorax, arms, and cranial nerves (CNs).
7. What is the life threatening com- Respiratory compromise from the paraly-
plication of Guillain-Barré syn- sis ascending into the thoracic region.
drome? - Monitoring for rate/depth of respirations
and measuring serial bedside vital capac-
ity (spirometry) help to detect this early in
the disease course.
8. The charge nurse is evaluating Places the patient with sepsis in high
the skills of a new registered fowlers position
nurse (RN) assigned to care for - this causes BP to decrease
a client with shock. Which action
taken by the new RN indicates a
need for further education?
9. What is pulmonary artery wedge indirect measure of pressure in the left
pressure? (PAWP) ventricle at the end of diastole
- 6-12
10. A registered nurse is precept- Requests that the doctor change continu-
ing a new nurse in the intensive ous feedings to bolus
care unit. The client is sedated - bolus feedings are contraindicated in
with propofol, on a mechanical most CC patients due to aspiration risk
ventilator, and is receiving enter-
al feeding via nasogastric tube.
The new nurse performs inter-
ventions to prevent aspiration.
The preceptor should intervene