NCLEX PN 2023 Quizlet - Nurselytic

Correct Answer: C

Rationale: In cases of trauma, the clothing of a client can hold crucial evidence that may have legal implications. It is essential for the nurse to avoid cutting through or disrupting any tears, holes, bloodstains, or dirt present on the clothing to preserve this potential evidence. The correct answer highlights the legal importance of preserving the clothing for potential legal implications.
Choice B is related but does not emphasize the legal aspect explicitly.
Choice C is vague in mentioning further investigation without specifying the legal significance.
Choice D focuses more on forensic analysis rather than the legal implications of preserving the clothing.

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: D

Rationale: It is crucial for the client to understand that consuming alcohol while on isoniazid can increase the risk of drug-induced hepatitis. Hepatic damage can lead to dark, concentrated urine.
To minimize gastrointestinal upset, it is recommended to take isoniazid with meals rather than on an empty stomach. Additionally, the client should avoid taking aluminum-containing antacids like aluminum hydroxide with isoniazid, as it can reduce the drug's effectiveness.
Choice A is incorrect because isoniazid should not be taken on an empty stomach to help reduce GI upset.
Choice B is incorrect, as prolonged use of isoniazid does not typically cause dark, concentrated urine.
Choice C is incorrect as taking aluminum hydroxide with isoniazid does not enhance the drug's effects; in fact, it may decrease its effectiveness.

Correct Answer: C

Rationale: The correct answer is C: lower right. Abdominal tenderness in the lower-right quadrant is a classic sign of appendicitis. The appendix is located in the lower right abdomen, so inflammation of the appendix typically causes tenderness in this specific area.

Choices A, B, and D are incorrect because tenderness in the upper right, upper left, and lower left quadrants, respectively, is not typical in appendicitis cases.
Therefore, the nurse should focus on assessing the lower right quadrant for tenderness when suspecting appendicitis.

Correct Answer: A

Rationale: The correct answer is peaches, eggs, beef. These are good sources of heme iron, which is more easily absorbed by the body compared to nonheme iron. Heme iron is mainly found in animal-based foods like meat, poultry, and fish. Peaches, eggs, and beef are rich in iron and can help prevent iron deficiency anemia.

Choices B, C, and D are incorrect because they do not include significant sources of heme iron. Cereals, kale, cheese, red beans, enriched breads, squash, legumes, and green beans are sources of nonheme iron, which is not as efficiently absorbed by the body as heme iron. It is important to include heme iron sources in the diet for optimal iron absorption.