NCLEX PN 2023 Quizlet - Nurselytic

Correct Answer: C

Rationale: The correct answer is 'trachea deviating to the right.' A mediastinal shift is indicative of a tension pneumothorax, which is a dangerous complication seen in trauma patients with symptoms like crepitus, decreased breath sounds, shortness of breath, and tachypnea. Assessing for acute traumatic injuries is crucial in this context.
Choice A, a temperature of 102°F and a productive cough, is common in pneumonia cases and not as concerning as a mediastinal shift.
Choice B, ABGs with a PaO2 of 92 mmHg and PaCO2 of 40 mmHg, shows values within normal limits and does not suggest a tension pneumothorax.
Choice D, a barrel-chested appearance, is typical of COPD and not directly related to the acute traumatic injury described. A tension pneumothorax is a medical emergency where air cannot escape the pleural cavity, leading to lung collapse and a mediastinal shift to the unaffected side with a downward displacement of the diaphragm.

Correct Answer: C

Rationale: The correct answer is Pitressin. Pitressin is a hormone replacement medication and is not classified as a neuromuscular blocker.

Choices A, B, and D (Anectine, Pavulon, Mivacron) are neuromuscular blockers used during anesthesia to induce muscle relaxation for various procedures. Anectine is also known as succinylcholine, Pavulon is rocuronium, and Mivacron is mivacurium. These medications act on the neuromuscular junction to block the transmission of nerve impulses, leading to muscle relaxation.

Correct Answer: C

Rationale: In this scenario, the client undergoing hemodialysis is experiencing symptoms like restlessness, a headache, and nausea. These symptoms are indicative of an air embolus, a serious complication that can occur during hemodialysis. Air embolus happens when air enters the bloodstream and can lead to symptoms like restlessness, a headache, and nausea. It is crucial for the nurse to suspect and address this complication promptly to prevent further harm to the client.

Choices A and D (Infection) are less likely in this case, as the symptoms presented are more suggestive of an air embolus rather than an infection.
Choice B (Disequilibrium syndrome) is also less likely as the symptoms described are not typical of this syndrome.
Therefore, the correct answer is C: Air embolus.

Correct Answer: C

Rationale: The appropriate nurse response is to explain to the employer that private information cannot be released and ask the employer to step out while conducting the assessment. This approach respects the client's privacy while still acknowledging the employer. The employer's payment for insurance does not grant rights to confidential information. Sharing information without permission violates the client's right to privacy under HIPAA. Option A is incorrect as it compromises the client's confidentiality by sharing private medical information. Option B is inappropriate and unprofessional as it does not address the situation respectfully. Option D is incorrect as it does not prioritize the client's immediate needs and assumes the client's consent without proper communication.

Correct Answer: D

Rationale: Vaccines are one of the most effective methods of preventing and controlling certain communicable diseases. The smallpox vaccine is not currently in use because the smallpox virus has been declared eradicated from the world's population. Diseases such as polio, diphtheria, pertussis, and measles are mostly controlled by routine childhood immunization. They have not, however, been eradicated, so children need to be immunized against these diseases.

Choices A, B, and C contain vaccines that do not protect against preventable diseases like polio, pertussis, and measles.
Therefore, the correct choice is D.