CRITICAL CARE: NCLEX QUESTION REVIEW

Question 1

A client in the intensive care unit (ICU) is experiencing signs of increased afterload resulting from acute blood loss. What does the nurse understand to be the effects on the heart

1. Name 2 states/actions that INCREASE AFTERLOAD

Answer 1

• Decreased stroke volume
• Increased ventricular work
• Increased myocardial oxygen requirements

Explanation:
Increased afterload resulting from hypovolemia or vasoconstriction will affect the heart by decreasing stroke volume, increasing ventricular work, and increasing myocardial oxygen requirements

Question 2

GI TUBE FEEDING

The nurse is observing a graduate nurse providing a tube feeding to a client. The nurse recognizes an unsafe practice and intervenes when the graduate nurse:

1. HOB what position for TUBE Feeding?

Answer 2

1. The client’s head should be greater than 30 degrees.

Question 3

GI TUBE FEEDING

Gold standard to verify tube placement?

Answer 3

x-ray

Question 4

The client is receiving ventilation through a spontaneous bi-level positive airway pressure (BiPAP) device. The nurse observes the client to ensure the device delivers a breath when the client initiates it.

1. The spontaneous BiPAP device is one in which the client triggers all?
2. Fit of Mask?
3. Covering?

Answer 4

1. The spontaneous BiPAP device is one in which the client triggers all breaths with inhalation. The device is not set to deliver a certain number of breaths per minute.
2. The device attaches to a tight fitting mask
3. around the mouth and/or nose.

Question 5

A client with a fractured hip is admitted through the emergency department. Past medical history includes a right mastectomy. The nurse notes a peripheral intravenous catheter has been inserted in the right hand. The nurse first intervenes by?

Answer 5

Discontinuing the intravenous site and starting a new site in the left arm

Question 6

The client is on a mechanical ventilator and has been on bedrest since admission to the intensive care unit following surgery. Prior to assisting the client to a bedside chair, it is most important for the nurse to assess the client’s (2)?

Answer 6

Blood Pressure and Pulse

Question 7

1. PVC
2. Inserted where?
3. Can be used for? (3)

Answer 7

1. In medicine, a peripheral venous catheter (PVC or peripheral venous line or peripheral venous access catheter) is a catheter (small, flexible tube)
2. placed into a **peripheral vein **
3. in order to administer medication or fluids. Upon insertion, the line can be used to draw blood.

Question 8

1. The client received 2 mg of morphine intravenously for a report of postoperative abdominal pain. Twenty minutes later, the client is cyanotic, respirations are 8 breaths per minute, and the client responds only when stimulated. The best action of the nurse is to?
2. S/S listed above indicate?

Answer 8

Contact the rapid response team.
Explanation:
The client needs a narcotic reversal agent. Most facilities employ a rapid response team that follows protocols that allow the administration of the reversal agent.

Question 9

carbamazepine

An adolescent presented to the emergency department with increasing frequency of seizures. The client has a history of epilepsy and has been taking carbamazepine (Tegretol) as prescribed. It is most important for the nurse to

Answer 9

Check the blood level of carbamazepine.

Question 10

ventricular assist device (VAD)

The client has a ventricular assist device (VAD) for class IV heart failure. It is most important for the nurse to make the following assessment every hour:?

Answer 10

Urine output

The nurse assesses urinary output every hour to check renal function.

Question 11

Q: The nurse has assessed the client for any impairment to the client’s skin upon admission. What data about the client place the client at risk for a pressure ulcer?

A: The client has experienced nausea and vomiting for 3 days.

Name other risk factors for pressure ulcers

Answer 11

A risk factor for a pressure ulcer is malnutrition, such as that seen in the client who has experienced nausea and vomiting for 3 days. Other risk factors include hemodynamic instability (the client has stable vital signs), advanced age (54 years is not considered advanced), and mobility deficits (the client can move all extremities).

Question 12

The nurse is caring for the client with decreased secretion of antidiuretic hormone (diabetes insipidus). What medication does the nurse anticipate administering for the treatment of diabetes insipidus?

You selected: Prednisone
Incorrect

Correct response:

Answer 12

Correct response: Arginine vasopressin
Explanation:
Treatment for decreased secretion of ADH is replacement of the hormone via one of the various forms of ADH, more commonly known as **arginine vasopressin **

Question 13

1. Two methods that allow for airway protection in the event of neurological deterioration or acute intoxication.(2)

Answer 13

A client with ascending paralysis from Guillain-Barre syndrome requires assistance to maintain the airway and promote adequate gas exchange. With what method of airway protection does the nurse anticipate assisting?

G⇒B muscle paralysis is foot to head GROUND⇒BRAIN

Explanation:
Intubation and ventilation allow for airway protection in the event of neurological deterioration or acute intoxication.