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. A client experiencing acute dyspnea and diaphoresis reports anxiety and difficulty breathing. Vital signs include HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. What should the nurse prioritize?

• A. Notify the provider.
• B. Administer heparin via IV infusion.
• C. Administer oxygen therapy.
• D. Obtain a spiral CT scan.

Correct answer: C

Rationale: In a client with acute dyspnea, diaphoresis, tachycardia, tachypnea, fever, and hypotension, the priority is to ensure adequate oxygenation. Administering oxygen therapy helps improve oxygenation levels and stabilize the client's condition. This intervention takes precedence over notifying the provider, administering heparin, or obtaining a CT scan, as oxygen therapy addresses the client's immediate need for respiratory support.

3. A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Which of the following nursing interventions would be appropriate?

• A. Encourage the patient to walk in the hall alone
• B. Discourage the patient from walking in the hall for a few more days
• C. Accompany the patient for his walk
• D. Consult a physical therapist before allowing the patient to ambulate

Correct answer: C

Rationale: Accompanying the patient for his walk is the appropriate nursing intervention in this scenario to ensure his safety during his first ambulation. This allows the nurse to provide immediate assistance if needed and ensures the patient's well-being during this critical postoperative period.

4. A healthcare professional is monitoring a group of clients for increased risk of developing pneumonia. Which of the following clients should the healthcare professional NOT expect to be at risk?

• A. Client who has dysphagia
• B. Client who has AIDS
• C. Client who was vaccinated for pneumococcus and influenza 6 months ago
• D. Client who has a closed head injury and is receiving ventilation

Correct answer: C

Rationale: A client who was vaccinated for pneumococcus and influenza 6 months ago would have a reduced risk of developing pneumonia compared to those who have not been vaccinated. Vaccination helps protect individuals from specific pathogens, thereby lowering the risk of infection. Clients with dysphagia, AIDS, or a closed head injury and receiving ventilation are at higher risk for pneumonia due to compromised immunity, respiratory function, or protective airway reflexes, respectively.

5. The healthcare professional must verify the client’s identity before the administration of medication. Which of the following is the safest way to identify the client?

• A. Ask the client for their name
• B. Check the client’s identification band
• C. State the client’s name aloud and ask the client to repeat it
• D. Check the room number

Correct answer: B

Rationale: Verifying the client's identity before administering medication is crucial to ensure patient safety. Checking the client’s identification band is the safest and most reliable method to confirm the client's identity. Identification bands are specifically designed to prevent errors in patient identification and help healthcare professionals administer care to the correct individual. Asking the client for their name (Choice A) may lead to errors if the client is unable to communicate or if there is a language barrier. Stating the client’s name aloud and asking them to repeat it (Choice C) relies on the client's ability to respond accurately. Checking the room number (Choice D) does not directly confirm the client's identity and may lead to errors if multiple patients are in the same room.

Similar Questions