NCLEX-PN Quizlet 2023 - Nurselytic

Correct Answer: D

Rationale: Signs of impaired breathing in infants and children typically include nasal flaring, grunting, and seesaw breathing. Nasal flaring is the widening of the nostrils during breathing to help with air intake, grunting is a sound made during expiration to keep the airway open, and seesaw breathing is an abnormal pattern where the chest moves in while the abdomen moves out. Quivering lips are not a typical sign of impaired breathing in infants and children, making it the correct answer. Nasal flaring, grunting, and seesaw breathing are all signs indicating the need for immediate medical attention due to potential respiratory distress.

Correct Answer: B

Rationale: The correct answer is 'Fever and anemia.' Zidovudine (Retrovir) is known to cause anemia as a side effect due to its impact on the bone marrow. Fever is also a common side effect associated with Zidovudine use.
Therefore, the patient should watch out for these specific side effects.
Choice A (Weakness and SO
B) is incorrect as shortness of breath (SO
B) is not a commonly reported side effect of Zidovudine.
Choice C (Hypertension and SO
B) and
Choice D (Fever and hypertension) are unrelated to the known side effects of Zidovudine, making them incorrect.

Correct Answer: B

Rationale: The correct answer is 'rapid cell catabolism.' Chemotherapy leads to the destruction of cells, resulting in increased uric acid levels due to cell breakdown.
Choice A is incorrect because the issue is not with the kidneys' ability to excrete the drug metabolites but rather with the cell breakdown.
Choice C is incorrect as the question focuses on chemotherapy and its effects, not prophylactic antibiotics.
Choice D is incorrect as the question pertains to the development of high uric acid levels, not altered blood pH from acidic drugs.

Correct Answer: C

Rationale: In this scenario, the nurse is observing bruises on a child's body that are located in areas not commonly associated with accidental injuries. Given the concerning nature of the bruising pattern and the inconsistent history provided by the parents, the nurse should suspect possible child abuse and take appropriate action by notifying the case manager in the clinic. The safety and well-being of the child should always be the top priority. Counseling for the family, warm baths, or recommending range of motion (ROM) exercises are not appropriate actions in this situation and may not address the underlying issue of potential child abuse.

Correct Answer: B

Rationale: The liver is crucial in processing nutrients and medications received through total parenteral nutrition. Liver function tests assess various enzymes produced by the liver, including prothrombin time/partial prothrombin time, serum glutamic oxaloacetic and pyruvic transaminases, gamma glutamyl transpeptidase, albumin, and alkaline phosphatase. Monitoring these enzymes can help determine if the liver is functioning properly to metabolize the nutrients from TPN. Triglyceride levels (
Choice
A) primarily evaluate the body's ability to clear fats, not specifically related to TPN tolerance. A glucose tolerance test (
Choice
C) is used to diagnose diabetes by measuring blood glucose levels after ingesting a glucose-rich solution, not directly related to TPN tolerance. A complete blood count (
Choice
D) assesses blood components such as red blood cells, white blood cells, and platelets but does not provide specific information about TPN tolerance.