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Critical Care Nursing
Certification Exam: Latest
Questions with Evidence-Based
Rationales
**1. A nurse is caring for a client who has a new diagnosis of
tuberculosis (TB) and is placed on airborne precautions. Which of the
following actions should the nurse take?**
A. Keep the door to the client’s room open at all times.
B. Wear an N95 respirator when entering the room.
C. Have the client wear a surgical mask while in their room alone.
D. Place the client in a semi-private room with another TB client.
**Answer: B**
**Rationale:** Airborne precautions require an N95 respirator (or
higher) for the healthcare worker. The door must remain closed, and
the client should wear a surgical mask when outside the room. A
negative-pressure airborne infection isolation room (AIIR) is required,
not a semi-private room.
- A is incorrect: The door must be closed to maintain negative pressure.
,- C is incorrect: The client does not need to wear a mask alone in their
room; they wear it when leaving.
- D is incorrect: Airborne precautions require a private AIIR.
**2. A nurse is preparing to transfer a client from bed to a stretcher.
Which action best demonstrates proper body mechanics?**
A. Twisting at the waist while pulling the client.
B. Keeping feet together and lifting with the back.
C. Positioning the bed at waist height and using a draw sheet.
D. Bending at the hips with knees straight.
**Answer: C**
**Rationale:** Proper body mechanics include positioning the bed at
waist height, keeping feet shoulder-width apart, bending at the knees,
and using assistive devices like a draw sheet.
- A and B increase risk of back injury.
- D places strain on the lower back.
**3. A nurse on a medical-surgical unit is assigning tasks to an LPN/LVN
and an unlicensed assistive personnel (UAP). Which task should the
nurse delegate to the LPN/LVN?**
A. Bathing a client with stable angina.
B. Feeding a client who had a stroke 2 years ago.
C. Administering a tube feeding via gastrostomy tube.
,D. Ambulating a client with a fractured hip post-op day 1.
**Answer: C**
**Rationale:** LPN/LVNs can administer tube feedings, monitor stable
clients, and perform sterile procedures in some states. UAP can
perform bathing, feeding, and ambulating stable clients.
- A, B, D are appropriate for UAP.
**4. A client with a history of seizures is prescribed phenytoin
(Dilantin). The nurse notes that the client’s serum phenytoin level is 22
mcg/mL (therapeutic range 10–20). Which action is priority?**
A. Administer the next dose as ordered.
B. Hold the next dose and notify the provider.
C. Check the client’s blood glucose level.
D. Increase the client’s fluid intake.
**Answer: B**
**Rationale:** Level 22 mcg/mL is above therapeutic range, indicating
toxicity. Symptoms include nystagmus, ataxia, and sedation. The nurse
should hold the dose and notify the provider.
- A would worsen toxicity.
- C and D are not directly relevant.
, **5. A nurse is caring for a client with a central venous catheter (CVC).
Which finding requires immediate intervention?**
A. Redness at the insertion site.
B. Blood return on aspiration.
C. Client report of shortness of breath.
D. Dressing changed 48 hours ago.
**Answer: C**
**Rationale:** Shortness of breath in a client with a CVC may indicate
an air embolism, pneumothorax, or catheter-related thrombosis. This is
a life-threatening emergency.
- A is important but not immediate.
- B is expected.
- D is within standard (change every 7 days or per protocol).
**6. A nurse is providing discharge teaching to a client after a total hip
arthroplasty. Which statement by the client indicates a need for further
teaching?**
A. “I will use a raised toilet seat.”
B. “I will not cross my legs when sitting.”
C. “I can bend forward to tie my shoes.”
D. “I will place a pillow between my legs when sleeping.”
Critical Care Nursing
Certification Exam: Latest
Questions with Evidence-Based
Rationales
**1. A nurse is caring for a client who has a new diagnosis of
tuberculosis (TB) and is placed on airborne precautions. Which of the
following actions should the nurse take?**
A. Keep the door to the client’s room open at all times.
B. Wear an N95 respirator when entering the room.
C. Have the client wear a surgical mask while in their room alone.
D. Place the client in a semi-private room with another TB client.
**Answer: B**
**Rationale:** Airborne precautions require an N95 respirator (or
higher) for the healthcare worker. The door must remain closed, and
the client should wear a surgical mask when outside the room. A
negative-pressure airborne infection isolation room (AIIR) is required,
not a semi-private room.
- A is incorrect: The door must be closed to maintain negative pressure.
,- C is incorrect: The client does not need to wear a mask alone in their
room; they wear it when leaving.
- D is incorrect: Airborne precautions require a private AIIR.
**2. A nurse is preparing to transfer a client from bed to a stretcher.
Which action best demonstrates proper body mechanics?**
A. Twisting at the waist while pulling the client.
B. Keeping feet together and lifting with the back.
C. Positioning the bed at waist height and using a draw sheet.
D. Bending at the hips with knees straight.
**Answer: C**
**Rationale:** Proper body mechanics include positioning the bed at
waist height, keeping feet shoulder-width apart, bending at the knees,
and using assistive devices like a draw sheet.
- A and B increase risk of back injury.
- D places strain on the lower back.
**3. A nurse on a medical-surgical unit is assigning tasks to an LPN/LVN
and an unlicensed assistive personnel (UAP). Which task should the
nurse delegate to the LPN/LVN?**
A. Bathing a client with stable angina.
B. Feeding a client who had a stroke 2 years ago.
C. Administering a tube feeding via gastrostomy tube.
,D. Ambulating a client with a fractured hip post-op day 1.
**Answer: C**
**Rationale:** LPN/LVNs can administer tube feedings, monitor stable
clients, and perform sterile procedures in some states. UAP can
perform bathing, feeding, and ambulating stable clients.
- A, B, D are appropriate for UAP.
**4. A client with a history of seizures is prescribed phenytoin
(Dilantin). The nurse notes that the client’s serum phenytoin level is 22
mcg/mL (therapeutic range 10–20). Which action is priority?**
A. Administer the next dose as ordered.
B. Hold the next dose and notify the provider.
C. Check the client’s blood glucose level.
D. Increase the client’s fluid intake.
**Answer: B**
**Rationale:** Level 22 mcg/mL is above therapeutic range, indicating
toxicity. Symptoms include nystagmus, ataxia, and sedation. The nurse
should hold the dose and notify the provider.
- A would worsen toxicity.
- C and D are not directly relevant.
, **5. A nurse is caring for a client with a central venous catheter (CVC).
Which finding requires immediate intervention?**
A. Redness at the insertion site.
B. Blood return on aspiration.
C. Client report of shortness of breath.
D. Dressing changed 48 hours ago.
**Answer: C**
**Rationale:** Shortness of breath in a client with a CVC may indicate
an air embolism, pneumothorax, or catheter-related thrombosis. This is
a life-threatening emergency.
- A is important but not immediate.
- B is expected.
- D is within standard (change every 7 days or per protocol).
**6. A nurse is providing discharge teaching to a client after a total hip
arthroplasty. Which statement by the client indicates a need for further
teaching?**
A. “I will use a raised toilet seat.”
B. “I will not cross my legs when sitting.”
C. “I can bend forward to tie my shoes.”
D. “I will place a pillow between my legs when sleeping.”
