NCLEX PN Exam Cram - Nurselytic

Correct Answer: A

Rationale: The correct answer is to tell the patient to remain with the leg straight for at least another hour after a heart catheterization before starting ambulation. This period allows for proper healing and reduces the risk of complications such as bleeding or hematoma formation at the catheter insertion site. Starting ambulation too soon can disrupt the healing process and lead to adverse events.
Choice B is incorrect because limited ambulation should not be initiated shortly after the procedure as it may increase the risk of complications.
Choice C is incorrect as physical therapy consultation is not typically necessary for initial ambulation post-heart catheterization; this can be managed by nursing staff.
Choice D is incorrect as keeping the leg straight for 6 hours is excessive and unnecessary, potentially leading to complications such as deep vein thrombosis due to prolonged immobility.

Correct Answer: C

Rationale: The correct answer is C. Patient confidentiality must be maintained at all times to respect the patient's privacy and dignity. Disclosing sensitive information like a patient's prognosis in a public setting violates confidentiality and can cause distress. The nurse should intervene in this situation and educate the nursing student about the importance of not discussing confidential patient information in public.

Choices A, B, and D do not involve breaching patient confidentiality and do not require immediate nurse intervention.
Choice A focuses on infection control measures, choice B relates to clinical assessment, and choice D is about the doctor's rounds, which are not urgent matters requiring immediate intervention.

Correct Answer: C

Rationale: Tuberculosis, caused by Mycobacterium tuberculosis, primarily affects the respiratory system. This aerobic bacillus thrives in highly oxygenated body sites, such as the lungs, growing ends of bones, and the brain. The bacillus is airborne, making the lungs a common site for infection.

Choices A, B, and D are incorrect as tuberculosis predominantly impacts the respiratory system and rarely involves the stomach, heart, or skin.

Correct Answer: C

Rationale: A colostomy is an opening between the colon and abdominal wall. An ileostomy is an opening between the ileum and abdominal wall, not the colon. Jejunostomy is an opening between the jejunum and abdominal wall, and cecostomy is an opening into the cecum. The term 'colostomy' specifically refers to the surgical procedure where a part of the colon is brought through the abdominal wall to create a stoma, allowing feces to leave the body.
Therefore, the correct answer is colostomy as it accurately describes the opening between the colon and the abdominal wall, distinct from the other options.

Correct Answer: D

Rationale: The correct answer is Digitalis. Digitalis is known to cause a flat T wave, depressed ST segment, and a short QT interval on an ECG report. These ECG changes are characteristic of digitalis toxicity. Morphine is not typically associated with these ECG changes. Atropine is more commonly linked to increasing heart rate rather than causing these specific ECG abnormalities. Procardia is a calcium channel blocker that does not typically produce the described ECG findings.
Therefore, Digitalis is the most likely medication causing these effects in the patient.