While preparing the client for a colonoscopy, the nurse's responsibilities include:
A. Explaining the risks and benefits of the exam
B. Instructing
... [Show More] the client about the bowel preparation prior to the test
C. Instructing the client about medication that will be used to sedate the client
D. Explaining the results of the exam - B. Instructing the client about the bowel preparation prior to the test
A certified nursing assistant is collecting a 24-hour urine specimen from a client. Which statement by the assistant indicates that the specimen collection will need to be restarted?
A. "I used a container from the lab that has a preservative in it."
B. "The client voided in it right away, and I wrote the time on the container."
C. "I have the container in a plastic bucket with ice in it."
D. "I told the client that every single urination must be put in the container. If one is missed, call one of us." - B. "The client voided in it right away, and I wrote the time on the container."
A client is admitted with gastrointestinal bleeding. One of the earliest and most important blood tests completed will be:
A. Electrolyte Panel
B. Arterial Blood Gases
C. Liver Panel
D. Complete Blood Count - D. Complete Blood Count
A client is to obtain a clean-catch urine specimen. Which statement by the client demonstrates a lack of understanding regarding the procedure?
A. "I should use all of the towelettes in the kit and use each only once."
B. "Urinate into the cup as soon as I start to go."
C. "I don't have to fill the cup. Just get an ounce or two."
D. "Put the cover on right away, without touching the inside of the cover or the cup." - B. "Urinate into the cup as soon as I start to go."
The nurse is having difficulty obtaining a capillary blood sample from a client's finger to measure blood glucose using a blood glucose monitor. Which procedure will increase the blood flow to the area to ensure an adequate specimen?
A. Raise the hand on a pillow to increase venous flow.
B. Pierce the skin with the lancet in the middle of the finger pad.
C. Wrap the finger in a warm cloth for 30--60 seconds.
D. Pierce the skin at a 45-degree angle. - C. Wrap the finger in a warm cloth for 30--60 seconds.
A client has a streptococcal throat infection. The White Blood Cell count is elevated. When looking at the differential, the nurse expects which type of white blood cell to be elevated?
A.Eosinophils
B. Monocytes
C. Lymphocytes
D. Neutrophils - D. Neutrophils
A client is to have a thoracentesis in order to aspirate pleural fluid for biopsy. In order to prepare the client for the procedure, the nurse best positions the client in which manner?
A. Lying in a lateral position with the affected lung down and back, curved into a fetal position. The head is supported with a pillow. The arms are positioned comfortably away from the chest wall.
B. Lying in a 10-degree reverse Trendelenburg position with the arms over the head. Small pillows allowed under the head and arms.
C. Sitting in a Fowler's position with the arms abducted and supported by pillows placed on each side of the body. The head is lying flat against the mattress.
D. Sitting on the side of the bed, leaning over a bedside table with a pillow on it, arms overhead supported by the pillow - D. Sitting on the side of the bed, leaning over a bedside table with a pillow on it, arms overhead supported by the pillow
A nurse cares for a client following a liver biopsy. Which nursing care plan reflects proper care?
A. Position in a dorsal recumbent position, with one pillow under the head
B. Bed rest for 24 hours, with a pressure dressing over the biopsy site
C. Position to a right side-lying position, with a pillow under the biopsy site
D. Neurological checks of lower extremities every hour - C. Position to a right side-lying position, with a pillow under the biopsy site
A client reports an iodine allergy. This information is most significant if the client is scheduled for which exam?
A. Lung Scan
B. Computed Tomography
C. Magnetic Resonance Imaging
D. Intravenous Pyelogram - D. Intravenous Pyelogram
Following a gastroscopy, a client asks for something to eat. The nurse correctly responds:
A. "I will first check your gag reflex."
B. "I will first listen for bowel sounds."
C. "I will first have you cough and deep-breathe."
D. "I will first listen to your lungs." - A. "I will first check your gag reflex."
The nurse would call the primary care provider immediately for which laboratory result?
A. Hgb = 16 g/dL for a male client.
B. Hct = 22% for a female client.
C. WBC = 9 x 10³/mL³
D. Platelets = 300 x 10³/mL³ - B. Hct = 22% for a female client.
A 78-year-old male client needs to complete a 24-hour urine specimen. In planning his care, the nurse realizes that which measure is most important?
A. Instruct the client to empty his bladder and save this voiding to start the collection.
B. Instruct the client to use sterile individual containers to collect the urine.
C. Post a sign stating "Save All Urine" in the bathroom.
D. Keep the urine specimen in the refrigerator. - C. Post a sign stating "Save All Urine" in the bathroom.
Option 3 is the most important nursing measure. This will inform the staff that the client is on a 24-hour urine collection. Option 1 is not appropriate since the first voided specimen is to be discarded. Option 2 is not an appropriate nursing measure since the specimen container is clean not sterile, and one container is needed—not individual containers. Option 4 is inappropriate because some 24-hour urine collections do not require refrigeration.
The client has a urinary health problem. Which procedure is performed using indirect visualization?
A. Intravenous pyelography (IVP)
B. Kidneys, ureter, bladder (KUB)
C. Retrograde pyelography
D. Cystoscopy - B. Kidneys, ureter, bladder (KUB)
A KUB is an x-ray of the kidneys, ureters, and bladder. This does not require direct visualization. Option 1 is an IVP, an intravenous pyelogram, which requires the injection of a contrast media. Option 3 is a retrograde pyelography, which requires the injection of a contrast media. Option 4 is a cytoscopy, which uses a lighted instrument (cystoscope) inserted through the urethra, resulting in direct visualization.
Which noninvasive procedure provides information about the physiology or function of an organ?
A. Angiography
B. Computerized tomography (CT)
C. Magnetic resonance imaging (MRI)
D. Positron emission tomography (PET) - D. Positron emission tomography (PET)
Rationale: This type of nuclear scan demonstrates the ability of tissues to absorb the chemical to indicate the physiology and function of an organ. Option 1 is an invasive procedure that focuses on blood flow through an organ. Options 2 and 3 provide information about density of tissue to help distinguish between normal and abnormal tissue of an organ.
When assisting with a bone marrow biopsy, the nurse should take which action?
A. Assist the client to a right side-lying position after the procedure.
B. Observe for signs of dyspnea, pallor, and coughing.
C. Assess for bleeding and hematoma formation for several days after the procedure.
D. Stand in front of the client and support the back of the neck and knees. - C. Assess for bleeding and hematoma formation for several days after the procedure.
Rationale: Bone marrow aspiration includes deep penetration into soft tissue and large bones such as the sternum and iliac crest. This penetration can result in bleeding. The client should be observed for bleeding in the days following the procedure. Option 1 is a nursing action during a liver biopsy. Option 2 is a nursing action for a thoracentesis, and Option 4 is a nursing action for a lumbar puncture.
During an assessment, the nurse learns that the client has a history of liver disease. Which diagnostic tests might be indicated for this client?Select all that apply.
A. Alanine aminotransferase (ALT)
B. Myoglobin
C. Cholesterol
D. Ammonia
E. Brain natriuretic peptide or B-Type natriuretic peptide (BNP) - A.Alanine aminotransferase (ALT)
D. Ammonia
ALT is an enzyme that contributes to protein and carbohydrate metabolism. An increase in the enzyme indicates damage to the liver.The liver contributes to the metabolism of protein, which results in the production of ammonia. If the liver is damaged, the ammonia level is increased.
Options 2, 3, and 5 (myoglobin, cholesterol, and BNP) are relevant for heart disease.
The nurse practitioner requests a laboratory blood test to determine how well a client has controlled her diabetes during the past 3 months. Which blood test will provide this information?
A. Fasting blood glucose
B. Capillary blood specimen
C. Glycosylated hemoglobin
D. GGT (gamma-glutamyl transferase) - C. Glycosylated hemoglobin
A glycosylated hemoglobin will indicate the glucose levels for a period of time, which is indicated by the nurse practitioner.
Options 1 and 2 will provide information about the current blood glucose not the past history. Option 4 is used to assess for liver disease.
The client is supposed to have a fecal occult blood test done on a stool sample. The nurse is going to use the Hemoccult test. Which of the following indicates that the nurse is using the correct procedure? Select all that apply.
A. Mixes the reagent with the stool sample before applying to the card.
B. Collects a sample from two different areas of the stool specimen.
C. Assesses for a blue color change.
D. Asks a colleague to verify the pink color results.
E. Asks the client if he has taken vitamin C in the past few days. - B. Collects a sample from two different areas of the stool specimen.
C. Assesses for a blue color change.
E. Asks the client if he has taken vitamin C in the past few days.
Rationale: The nurse should obtain the stool specimen from two different areas of the stool.The nurse should observe for a blue color change, which is indicative of a positive result.The nurse should assess for the ingestion of vitamin C by the client because it is contraindicated for 3 days prior to taking the specimen.
Option 1 is incorrect since the reagent is placed on the specimen after it is applied to the testing card. Option 4 is incorrect because a pink color would be considered negative and does not require verification.
A primary care provider is going to perform a thoracentesis. The nurse's role will include which action?
A. Place the client supine in the Trendelenburg position.
B. Position the client in a seated position with elbows on the overbed table.
C. Instruct the UAP to measure vital signs.
D. Administer an opioid analgesic. - B. Position the client in a seated position with elbows on the overbed table.
The nurse needs to collect a sputum specimen to identify the presence of tuberculosis (TB). Which nursing action(s) is/are indicated for this type of specimen? Select all that apply.
A. Collect the specimen in the evening.
B. Send the specimen immediately to the laboratory.
C. Ask the client to spit into the sputum container.
D. Offer mouth care before and after collection of the sputum specimen.
E. Collect a specimen for 3 consecutive days. - B. Send the specimen immediately to the laboratory.
D. Offer mouth care before and after collection of the sputum specimen.
E. Collect a specimen for 3 consecutive days [Show Less]