Quizlet NCLEX PN 2023 - Nurselytic

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.

Correct Answer: D

Rationale: A dark red color is an abnormal finding when assessing the stoma as it indicates inadequate blood supply, possibly due to ischemia. Mild edema, minimal bleeding, and a rose color are expected findings one day post colostomy surgery. Mild edema can be present due to tissue trauma and inflammation, minimal bleeding can occur initially, and a healthy stoma typically appears pink to red, known as a rose color, indicating good blood supply and tissue perfusion.
Therefore, the dark red color is the abnormal finding in this scenario.

Correct Answer: C

Rationale: When a client has early impairment of oxygen perfusion, such as in a pulmonary embolus, the nurse should expect to find restlessness, diaphoresis, tachycardia, and cool skin. Tachycardia is a compensatory mechanism to increase oxygen delivery to tissues. Cool, clammy skin (choice
A) is more indicative of impaired oxygen perfusion compared to warm, dry skin. Bradycardia (choice
B) is less likely to occur in the early stages and is more common in severe cases. Eupnea (choice
D) refers to normal respirations in rate and depth, which may not be altered in early impairment of oxygen perfusion.

Correct Answer: B

Rationale: The correct answer is 'Sagittal.' The sagittal plane divides the body into left and right halves, and movements in this plane involve flexion and extension. In this case, limited shoulder flexion on the left indicates a restriction in the forward and backward movement of the arm, which occurs in the sagittal plane.
Choice A, 'Horizontal,' is incorrect as it refers to movements parallel to the ground.
Choice C, 'Frontal,' is incorrect as it involves side-to-side movements.
Choice D, 'Vertical,' is incorrect as it typically refers to up and down movements.

Correct Answer: A

Rationale: Active transport is the correct answer as it accurately describes the process involved in the sodium-potassium pump. The pump utilizes energy to move ions against their concentration gradient, maintaining cellular concentrations. Diffusion (choice
B) is a passive process where substances move from an area of higher concentration to lower concentration. Filtration (choice
C) involves the movement of solutes based on pressure gradients. Osmosis (choice
D) is the movement of water across a semipermeable membrane.