1
ELSIVER NCLEX CRITICAL CARE TEST WITH REAL EXAM QUESTIONS AND ANSWERS
[RATIONALES PROVIDED]
• A 2-year-old child is being transported to the trauma center from a local
community hospital for treatment of a burn injury that is estimated as
covering more than 40% of the body. The burns are both partial- and full-
thickness burns. The nurse is asked to prepare for the arrival of the child
and gathers supplies, anticipating that which treatment will be prescribed
initially?
1.Insertion of a Foley catheter
2.Insertion of a nasogastric tube
3.Administration of an anesthetic agent for sedation
4.Application of an antimicrobial agent to the burns
• Insertion of a Foley catheter
A Foley catheter is inserted into the child's bladder so that urine output can
be accurately measured on an hourly basis. Although pain medication may
be required, the child would not receive an anesthetic agent and should not
be sedated. The burn wounds would be cleansed after assessment, but this
would not be the initial action. Intravenous fluids are administered at a rate
sufficient to keep the child's urine output at 1 to 2 mL/kg of body weight
per hour for children weighing less than 30 kg, thus reflecting adequate
tissue perfusion. A nasogastric tube may or may not be required but would
not be the priority intervention.
• 3.: A 5-year-old boy is brought by his mother to the emergency department
after ingesting a bottle of acetylsalicylic acid. Which procedure should be
initially instituted with this child?
1.
Administer ipecac by mouth and monitor emesis.
2.
Institute a gastric lavage and administer activated charcoal.
3.
Administer a chelating agent such as edetate calcium disodium.
,2
4.
Institute a gastric lavage and administer the antidote
acetylcysteine.Institute a gastric lavage and administer activated charcoal.
A gastric lavage must be performed after ingestion of acetylsalicylic acid,
and activated charcoal is administered to prevent further absorption of the
substance. N-acetylcysteine is the antidote for acetaminophen.
Administering ipecac or edetate calcium disodium is not a treatment
measure for acetylsalicylic acid poisoning. Edetate calcium disodium may
be prescribed for the treatment of lead poisoning. Ipecac causes vomiting,
and this substance is used only in specific poisoning conditions; in this
situation, vomiting can cause irritation of the esophagus.
• 4.: Acetylcysteine is prescribed for a client in the hospital emergency
department after diagnosis of acetaminophen overdose. The nurse
prepares to administer the medication using which procedure?
1.
Diluting the medication in cola and administering it to the client orally
2.
Calling the respiratory department to administer the medication via inhaler
3.
Obtaining a 1-mL syringe to administer the small dose via the subcutaneous
route
4.
Obtaining an appropriate-size syringe and needle for intramuscular
injection in the ventrogluteal muscleDiluting the medication in cola and
administering it to the client orally
Acetylcysteine can be given orally or by nasogastric tube to treat
acetaminophen overdose. It is administered by inhalation for use as a
mucolytic. Before administration of the medication as an antidote, the
nurse would ensure that the client's stomach is empty through emesis or
gastric lavage. The solution is diluted in cola, water, or juice to make the
solution more palatable. It is not administered via nebulizer,
subcutaneously, or intramuscularly for the client experiencing
acetaminophen overdose.
,3
• 5.: An adult client has been unsuccessfully defibrillated for ventricular
fibrillation, and cardiopulmonary resuscitation (CPR) is resumed. The nurse
confirms that CPR is being administered effectively by noting which action?
1.
The ratio of compressions to ventilations is 30:2.
2.
The carotid pulse is palpable with each compression.
3.
Respirations are given at a rate of 10 breaths per minute.
4.
The chest compressions are given at a depth of 1.5 to 2 inches (2.5 to 5
cm).The carotid pulse is palpable with each compression.
With effective compressions, carotid pulsations should be present. At its
best, CPR produces only 30% of the normal cardiac output, so correct
technique is vital. Assessment of the carotid pulse during CPR is the most
accurate way to assess the effectiveness of CPR. Correct procedure for CPR
in an adult includes a compression-to-ventilation ratio of 30:2. With adults,
compressions are performed at a depth of at least 2 inches (5 cm). The 30:2
compression-to-ventilation ratio yields an effective rate of 10 breaths per
minute.
• 6.: Cardiopulmonary resuscitation (CPR) is immediately initiated on a client
who is unconscious and has no pulse. A monitor is attached and it is
determined that the rhythm is shockable, and defibrillation with 1 shock is
delivered. Which action should the nurse plan to take next?
1.
Defibrillate 1 more time, and then terminate the resuscitation effort.
2.
Administer a bolus of fluid intravenously, and resume defibrillation
attempts.
3.
Perform CPR for 5 cycles, and then defibrillate again if the rhythm is
shockable.
, 4
4.
Perform CPR for 1 minute, assess, and then defibrillate up to 3 more
times.Perform CPR for 5 cycles, and then defibrillate again if the rhythm is
shockable.
If a client is unconscious and has no pulse, the nurse would shout for help
(activate emergency response) and immediately initiate CPR. If the rhythm
is shockable, a shock is delivered and then CPR is delivered for 5 cycles. This
pattern is repeated 2 more times if the rhythm remains shockable.
Treatment with medications is also done during this time to reverse the
cause of the ventricular fibrillation. Each of the other options is incorrect.
• 7.: A child is admitted to the hospital after being seen in the emergency
department with complaints of right lower quadrant abdominal pain,
nausea and vomiting, fever, and chills. The health care provider (HCP)
suspects appendicitis. Which assessment finding should the nurse
immediately report to the HCP?
1.
Decreasing oral temperature
2.
Increasing complaints of pain
3.
Refusal to take fluids by mouth
4.
Sudden relief of abdominal painSudden relief of abdominal pain
A sudden relief of pain from a suspected appendicitis is commonly
indicative of a ruptured appendix. This places the individual at risk for
peritonitis and shock. The HCP should be notified immediately because of
the need to begin intravenous antibiotics to prevent further complications.
Although increasing complaints of pain is a concern, the higher priority is
sudden relief of pain because of the risk of peritonitis and shock.
Temperature should be monitored but is not of highest priority. The child
will be placed on NPO (nothing by mouth) status in anticipation of surgery;
therefore, option 4 is incorrect.
ELSIVER NCLEX CRITICAL CARE TEST WITH REAL EXAM QUESTIONS AND ANSWERS
[RATIONALES PROVIDED]
• A 2-year-old child is being transported to the trauma center from a local
community hospital for treatment of a burn injury that is estimated as
covering more than 40% of the body. The burns are both partial- and full-
thickness burns. The nurse is asked to prepare for the arrival of the child
and gathers supplies, anticipating that which treatment will be prescribed
initially?
1.Insertion of a Foley catheter
2.Insertion of a nasogastric tube
3.Administration of an anesthetic agent for sedation
4.Application of an antimicrobial agent to the burns
• Insertion of a Foley catheter
A Foley catheter is inserted into the child's bladder so that urine output can
be accurately measured on an hourly basis. Although pain medication may
be required, the child would not receive an anesthetic agent and should not
be sedated. The burn wounds would be cleansed after assessment, but this
would not be the initial action. Intravenous fluids are administered at a rate
sufficient to keep the child's urine output at 1 to 2 mL/kg of body weight
per hour for children weighing less than 30 kg, thus reflecting adequate
tissue perfusion. A nasogastric tube may or may not be required but would
not be the priority intervention.
• 3.: A 5-year-old boy is brought by his mother to the emergency department
after ingesting a bottle of acetylsalicylic acid. Which procedure should be
initially instituted with this child?
1.
Administer ipecac by mouth and monitor emesis.
2.
Institute a gastric lavage and administer activated charcoal.
3.
Administer a chelating agent such as edetate calcium disodium.
,2
4.
Institute a gastric lavage and administer the antidote
acetylcysteine.Institute a gastric lavage and administer activated charcoal.
A gastric lavage must be performed after ingestion of acetylsalicylic acid,
and activated charcoal is administered to prevent further absorption of the
substance. N-acetylcysteine is the antidote for acetaminophen.
Administering ipecac or edetate calcium disodium is not a treatment
measure for acetylsalicylic acid poisoning. Edetate calcium disodium may
be prescribed for the treatment of lead poisoning. Ipecac causes vomiting,
and this substance is used only in specific poisoning conditions; in this
situation, vomiting can cause irritation of the esophagus.
• 4.: Acetylcysteine is prescribed for a client in the hospital emergency
department after diagnosis of acetaminophen overdose. The nurse
prepares to administer the medication using which procedure?
1.
Diluting the medication in cola and administering it to the client orally
2.
Calling the respiratory department to administer the medication via inhaler
3.
Obtaining a 1-mL syringe to administer the small dose via the subcutaneous
route
4.
Obtaining an appropriate-size syringe and needle for intramuscular
injection in the ventrogluteal muscleDiluting the medication in cola and
administering it to the client orally
Acetylcysteine can be given orally or by nasogastric tube to treat
acetaminophen overdose. It is administered by inhalation for use as a
mucolytic. Before administration of the medication as an antidote, the
nurse would ensure that the client's stomach is empty through emesis or
gastric lavage. The solution is diluted in cola, water, or juice to make the
solution more palatable. It is not administered via nebulizer,
subcutaneously, or intramuscularly for the client experiencing
acetaminophen overdose.
,3
• 5.: An adult client has been unsuccessfully defibrillated for ventricular
fibrillation, and cardiopulmonary resuscitation (CPR) is resumed. The nurse
confirms that CPR is being administered effectively by noting which action?
1.
The ratio of compressions to ventilations is 30:2.
2.
The carotid pulse is palpable with each compression.
3.
Respirations are given at a rate of 10 breaths per minute.
4.
The chest compressions are given at a depth of 1.5 to 2 inches (2.5 to 5
cm).The carotid pulse is palpable with each compression.
With effective compressions, carotid pulsations should be present. At its
best, CPR produces only 30% of the normal cardiac output, so correct
technique is vital. Assessment of the carotid pulse during CPR is the most
accurate way to assess the effectiveness of CPR. Correct procedure for CPR
in an adult includes a compression-to-ventilation ratio of 30:2. With adults,
compressions are performed at a depth of at least 2 inches (5 cm). The 30:2
compression-to-ventilation ratio yields an effective rate of 10 breaths per
minute.
• 6.: Cardiopulmonary resuscitation (CPR) is immediately initiated on a client
who is unconscious and has no pulse. A monitor is attached and it is
determined that the rhythm is shockable, and defibrillation with 1 shock is
delivered. Which action should the nurse plan to take next?
1.
Defibrillate 1 more time, and then terminate the resuscitation effort.
2.
Administer a bolus of fluid intravenously, and resume defibrillation
attempts.
3.
Perform CPR for 5 cycles, and then defibrillate again if the rhythm is
shockable.
, 4
4.
Perform CPR for 1 minute, assess, and then defibrillate up to 3 more
times.Perform CPR for 5 cycles, and then defibrillate again if the rhythm is
shockable.
If a client is unconscious and has no pulse, the nurse would shout for help
(activate emergency response) and immediately initiate CPR. If the rhythm
is shockable, a shock is delivered and then CPR is delivered for 5 cycles. This
pattern is repeated 2 more times if the rhythm remains shockable.
Treatment with medications is also done during this time to reverse the
cause of the ventricular fibrillation. Each of the other options is incorrect.
• 7.: A child is admitted to the hospital after being seen in the emergency
department with complaints of right lower quadrant abdominal pain,
nausea and vomiting, fever, and chills. The health care provider (HCP)
suspects appendicitis. Which assessment finding should the nurse
immediately report to the HCP?
1.
Decreasing oral temperature
2.
Increasing complaints of pain
3.
Refusal to take fluids by mouth
4.
Sudden relief of abdominal painSudden relief of abdominal pain
A sudden relief of pain from a suspected appendicitis is commonly
indicative of a ruptured appendix. This places the individual at risk for
peritonitis and shock. The HCP should be notified immediately because of
the need to begin intravenous antibiotics to prevent further complications.
Although increasing complaints of pain is a concern, the higher priority is
sudden relief of pain because of the risk of peritonitis and shock.
Temperature should be monitored but is not of highest priority. The child
will be placed on NPO (nothing by mouth) status in anticipation of surgery;
therefore, option 4 is incorrect.
