Nursing Elites

1. A client has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests?

• A. Platelet count
• B. Potassium level
• C. Creatinine clearance
• D. Prealbumin

Correct answer: A

Rationale: Generalized petechiae and ecchymoses can indicate a potential issue with platelet function or count. Therefore, the most relevant laboratory test to evaluate this condition would be a platelet count. Platelet count helps assess the number of platelets in the blood, which are crucial for clotting and preventing bleeding. Monitoring platelet levels can provide important information about a client's bleeding risk and overall hematologic health.

2. Which of the following parameters should be checked when assessing respirations?

• A. Rate
• B. Rhythm
• C. Symmetry
• D. All of the above

Correct answer: D

Rationale: When assessing respirations, it is essential to evaluate the rate at which breaths are taken, the rhythm of breathing patterns, and the symmetry of chest expansion. Each of these parameters provides valuable information about a person's respiratory status. Therefore, it is important to assess all of the listed parameters to have a comprehensive understanding of the individual's respiratory function.

3. When a client is comatose and has advance directives stating a desire to avoid life-sustaining measures, but the family wants these measures, what action should the nurse take?

• A. Arrange for an ethics committee meeting to address the family's concerns.
• B. Support the family's decision and initiate life-sustaining measures.
• C. Complete an incident report.
• D. Encourage the family to contact an attorney.

Correct answer: A

Rationale: In this scenario, the nurse should prioritize the client's wishes as outlined in the advance directives. By arranging for an ethics committee meeting, the nurse can facilitate discussions between the family and healthcare team to ensure that the client's wishes are respected while addressing the concerns of the family. This approach promotes ethical decision-making and collaborative communication among all involved parties, ultimately aiming to provide the best possible care for the client while considering their autonomy and preferences.

4. What is the appropriate needle gauge for intradermal injection?

• A. 20G
• B. 22G
• C. 25G
• D. 26G

Correct answer: D

Rationale: Intradermal injections require a very fine needle to be used to deliver the medication into the dermis layer of the skin. A 26G needle is typically used for intradermal injections as it is thin enough to penetrate the skin's surface and deposit the medication accurately.

5. A client is in a seclusion room following violent behavior and continues to display aggressive behavior. What action should the nurse take?

• A. Confront the client about this behavior.
• B. Express sympathy for the client's situation.
• C. Speak assertively to the client.
• D. Stand within 30 cm (1 ft) of the client when speaking with them.

Correct answer: A

Rationale: When a client in a seclusion room following violent behavior continues to display aggression, it is essential for the nurse to confront the client about this behavior. Confrontation can help set boundaries, address the behavior, and ensure the safety of both the client and the healthcare team. Expressing sympathy (Choice B) may not address the immediate need for behavior management. Speaking assertively (Choice C) can be important but should be coupled with addressing the specific behavior. Standing within close proximity (Choice D) of an aggressive client can escalate the situation and compromise safety, so it is not the appropriate action to take.

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