Quizlet NCLEX PN 2023 - Nurselytic

Correct Answer: C

Rationale: When a patient is acutely psychotic, they may not be able to effectively participate in group therapy due to their altered mental state. Group settings can be overwhelming and may exacerbate the patient's symptoms.

Choices A, B, and D are appropriate interventions.
Choice A is correct as providing calmness through one-on-one interaction can be beneficial in establishing trust and reducing anxiety.
Choice B is also important as recognizing and managing the nurse's feelings can prevent further escalation of the patient's symptoms.
Choice D is relevant as listening and identifying causes of the patient's behavior can aid in understanding and providing appropriate care tailored to the patient's needs.

Correct Answer: D

Rationale: In the case where medications are given to the wrong client, the appropriate documentation by the nurse should involve completely filling out an incident report. This report is essential for tracking errors, implementing corrective measures, and ensuring patient safety.
Choice A is incorrect because solely noting the drug given does not address the severity of the error.
Choice B is incorrect because even if the client was not hurt, documentation is crucial for quality improvement and risk prevention.
Choice C is incorrect as noting the client's orientation does not adequately address the medication error and its implications.

Correct Answer: B

Rationale: In this scenario, the patient's symptoms of shortness of breath (SO
B) and weakness in the lower extremities, along with a history of hyperlipidemia and hypertension, are suggestive of a myocardial infarction (MI). It is important to note that MI can present with a variety of symptoms, including those affecting the respiratory system and muscle weakness.

Choices A, C, and D are incorrect because the patient's symptoms are more indicative of a myocardial infarction rather than congestive heart failure (CHF), chronic obstructive pulmonary disease (COP
D), or peripheral vascular disease (PV
D).

Correct Answer: B

Rationale: In respiratory acidosis, the serum potassium level is expected to be elevated. This occurs because potassium shifts from cells into the bloodstream as a compensatory mechanism to maintain acid-base balance.

Choices A, C, and D are incorrect. A normal potassium level is not expected in respiratory acidosis. A low potassium level is more commonly associated with alkalosis, not acidosis. The potassium level is indeed related to pH changes in respiratory acidosis, leading to the expected elevation.

Correct Answer: B

Rationale: In a patient with COPD and CHF experiencing a sudden increase in total body weight, the priority is to check the intake and output on the patient's flow sheet to evaluate fluid balance. This assessment helps determine if the weight gain is due to fluid retention, which can exacerbate CHF. Contacting the physician may be necessary based on the intake and output findings. While encouraging ambulation is beneficial for circulation, it may not address the root cause of fluid retention. Checking vitals every 2 hours is important for monitoring stability but may not pinpoint the reason behind the weight gain.