NCLEX CRITICAL CARE NURSE QUESTION AND
ANSWERS 2024 LATEST VERSION GRADED A+
What are appropriate nursing interventions for the patient with delirium in the ICU? (Select all that
apply)
The use of clocks and calendars can help orient the patient with delirium in the intensive care unit (ICU).
If the patient demonstrates hyperactivity, insomnia, or delusions, management with neuroleptic drugs
(e.g., haloperidol [Haldol]) can be considered. Physical conditions such as hemodynamic instability,
hypoxemia, hypercarbia, electrolyte disturbances, and severe infections can precipitate delirium.
The nurse wants to assess the oxygenation status of a patient who has been experiencing a
gastrointestinal bleed. How will the nurse complete this assessment? Select all that apply.
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
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.
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.
occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever,
vomiting, diarrhea, hypotension, and the development of shock.
E. Identify physiological factors that may be contributing to the patient's confusion and irritability. -
ansA,C,E
E. Calculate mean arterial pressure - ansA. Use pulse oximetry
D. Silence all alarms, reduce overhead paging, and avoid conversations around the patient.
d. rechecks the location of the phlebostatic axis when changing the patient's position. - ansB positions
the zero-reference stopcock line level with the phlebostatic axis.
D. Evaluate cardiac rhythm strip
D. Delayed transfusion reaction - ansA. Septicemia
D. an individually devised plan to involve caregivers with care and comfort measures. - ansD. An
individually devised plan to involve caregivers with care and comfort measures.
C. Sedate the patient with appropriate drugs to protect the patient from harmful behaviors.
C. restriction of visiting in the ICU because the environment is overwhelming to caregivers.
c. ensures that the patient is supine with the head of the bed flat for all readings.
C. Circulatory overload
C. Auscultate lung sounds
ANSWERS 2024 LATEST VERSION GRADED A+
What are appropriate nursing interventions for the patient with delirium in the ICU? (Select all that
apply)
The use of clocks and calendars can help orient the patient with delirium in the intensive care unit (ICU).
If the patient demonstrates hyperactivity, insomnia, or delusions, management with neuroleptic drugs
(e.g., haloperidol [Haldol]) can be considered. Physical conditions such as hemodynamic instability,
hypoxemia, hypercarbia, electrolyte disturbances, and severe infections can precipitate delirium.
The nurse wants to assess the oxygenation status of a patient who has been experiencing a
gastrointestinal bleed. How will the nurse complete this assessment? Select all that apply.
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
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.
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.
occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever,
vomiting, diarrhea, hypotension, and the development of shock.
E. Identify physiological factors that may be contributing to the patient's confusion and irritability. -
ansA,C,E
E. Calculate mean arterial pressure - ansA. Use pulse oximetry
D. Silence all alarms, reduce overhead paging, and avoid conversations around the patient.
d. rechecks the location of the phlebostatic axis when changing the patient's position. - ansB positions
the zero-reference stopcock line level with the phlebostatic axis.
D. Evaluate cardiac rhythm strip
D. Delayed transfusion reaction - ansA. Septicemia
D. an individually devised plan to involve caregivers with care and comfort measures. - ansD. An
individually devised plan to involve caregivers with care and comfort measures.
C. Sedate the patient with appropriate drugs to protect the patient from harmful behaviors.
C. restriction of visiting in the ICU because the environment is overwhelming to caregivers.
c. ensures that the patient is supine with the head of the bed flat for all readings.
C. Circulatory overload
C. Auscultate lung sounds
