Nokea
The healthcare professional assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory results should the healthcare professional review?
- A. Red blood cell count
- B. Platelet count
- C. Hemoglobin levels
- D. White blood cell count
Correct Answer: B
Rationale: The platelet count is the most appropriate laboratory result to review in a client presenting with petechiae and ecchymosis. Petechiae and ecchymosis are indicative of potential bleeding issues, which can be caused by low platelet count or impaired platelet function. Platelets are essential for clotting, and a low platelet count can lead to bleeding disorders. Reviewing the platelet count will provide valuable information about the client's clotting ability.
Choice A, red blood cell count, is not typically associated with petechiae and ecchymosis. Hemoglobin levels (Choice C) are more related to anemia than bleeding disorders like thrombocytopenia. White blood cell count (Choice D) is not directly linked to the presence of petechiae and ecchymosis, which are more specific to platelet-related issues.
You may also like to solve these questions
The nurse is caring for a client who is receiving an IV infusion of normal saline and notices that the infusion is not flowing. The insertion site is not inflamed or swollen. What should the nurse do first?
- A. Check the tubing for kinks or obstructions.
- B. Increase the flow rate to improve the infusion.
- C. Reinsert the IV catheter in another vein.
- D. Call the physician for further instructions.
Correct Answer: A
Rationale: The correct first action for the nurse to take when an IV infusion is not flowing despite a normal insertion site is to check the tubing for kinks or obstructions. This step is crucial to ensure that there are no preventable issues impeding the flow of the IV solution. Increasing the flow rate without addressing potential obstructions could lead to complications such as infiltration. Reinserting the IV catheter in another vein should only be considered after ruling out tubing issues. Calling the physician for further instructions is not necessary at this stage as troubleshooting the tubing should be the initial intervention.
A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client's respiratory acidosis?
- A. Carbon dioxide is converted in the kidneys for elimination.
- B. Blood oxygen levels are stimulating the respiratory rate.
- C. Hyperventilation is eliminating carbon dioxide rapidly.
- D. High levels of carbon dioxide have accumulated in the blood.
Correct Answer: D
Rationale: The correct answer is D. High levels of carbon dioxide in the blood are indicative of respiratory acidosis, often due to inadequate ventilation. In respiratory acidosis, there is retention of carbon dioxide (hypercapnia) leading to an increase in carbonic acid levels in the blood, resulting in an acidic pH. Option A is incorrect because carbon dioxide elimination primarily occurs through the lungs, not the kidneys. Option B is incorrect because blood oxygen levels primarily affect the respiratory rate to regulate oxygen levels, not carbon dioxide levels. Option C is incorrect because hyperventilation would lead to a decrease, not an increase, in carbon dioxide levels.
The nurse is monitoring a client who is receiving continuous ambulatory peritoneal dialysis. The nurse should notify the physician of which of the following findings?
- A. Clear dialysate outflow.
- B. Cloudy dialysate outflow.
- C. Decreased urine output.
- D. Increased blood pressure.
Correct Answer: B
Rationale: Cloudy dialysate outflow is an indication of peritonitis, a serious complication of peritoneal dialysis that requires immediate medical attention. Clear dialysate outflow is a normal finding indicating proper dialysis function and should not raise concern. Decreased urine output may be expected in a client undergoing dialysis due to the removal of excess fluids from the body. Increased blood pressure is a common complication in clients with kidney disease but is not directly related to cloudy dialysate outflow.
While assessing a female client who is chronically fatigued and was recently diagnosed with adrenal insufficiency, the client tells the nurse that she is very nervous that her hospitalization will cause her to lose her job. Which intervention should the nurse implement first?
- A. Teach the client about the risk for infection.
- B. Offer support and care measures to reduce anxiety and stress.
- C. Encourage the client to rest quietly to reduce fatigue.
- D. Place a referral to social services to discuss financial options.
Correct Answer: B
Rationale: In this scenario, the priority intervention for the nurse is to offer support and care measures to reduce anxiety and stress. Addressing the client's emotional distress is crucial as the stress can exacerbate adrenal insufficiency. While teaching the client about the risk for infection (Choice A) is important, addressing the immediate emotional needs takes precedence. Encouraging the client to rest quietly (Choice C) is beneficial but does not directly address the client's current distress about job loss. Referring the client to social services (Choice D) for financial options is important, but at this moment, addressing the client's anxiety is the priority to promote emotional well-being.
The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can:
- A. Perform the procedure safely and correctly.
- B. Critique the nurse's performance of the procedure.
- C. Explain all steps of the procedure correctly.
- D. Correctly answer a post-test about the procedure.
Correct Answer: A
Rationale: The best indicator of learning is the ability to perform the procedure safely and correctly, demonstrating skill acquisition. Choice A is correct because the client's ability to perform the insulin self-injection safely and correctly shows practical understanding and application of the skill. Choice B is incorrect because critiquing the nurse's performance does not necessarily demonstrate the client's ability to carry out the procedure themselves. Choice C is incorrect as merely explaining the steps verbally does not confirm the client's practical execution of the task. Choice D is also incorrect as answering a post-test does not directly assess the client's ability to physically perform the insulin self-injection.