NCLEX Critical Care Nurse Question
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. -
correct answer-D. 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.
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 - correct answer-A. Septicemia
occurs with the transfusion of blood contaminated with microorganisms. Signs include chills,
fever, vomiting, diarrhea, hypotension, and the development of shock.
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.
d. rechecks the location of the phlebostatic axis when changing the patient's position. -
correct answer-B positions the zero-reference stopcock line level with the phlebostatic axis.
Rationale: For accurate measurement of pressures, the zero-reference level should be at the
phlebostatic axis. There is no need to rebalance and recalibrate monitoring equipment
hourly. Accurate hemodynamic readings are possible with the patient's head raised to 45
degrees or in the prone position. The anatomic position of the phlebostatic axis does not
change when patients are repositioned.
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