The nurse would call the primary care provider immediately for which laboratory result?
1. Hgb = 16 g/dL for a male client
2. Hct = 22% for a female client
3. WBC = 9 × 103/mL3
4. Platelets = 300 × 103/mL3
- Answer: 2. Rationale: Option 2 is very low and can lead to death. The client’s red blood cells participate in oxygenation. Options 1, 3, and 4 are within normal range and should not be reported to the primary care provider. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 34-3.
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?
1. Instruct the client to empty his bladder and save this voiding to start the collection.
2. Instruct the client to use sterile individual containers to collect the urine.
3. Post a sign stating “Save All Urine” in the bathroom.
4. Keep the urine specimen in the refrigerator.
- Answer: 3. Rationale: 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. Cognitive Level: Understanding. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 34-6.
The client has a urinary health problem. Which procedure is performed using indirect visualization? 1. Intravenous pyelography (IVP)
2. Kidneys, ureter, bladder (KUB)
3. Retrograde pyelography
4. Cystoscopy
- Answer: 2. Rationale: 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 cystoscopy, which uses a lighted instrument (cystoscope) inserted through the urethra, resulting in direct visualization. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 34-8.
Which noninvasive procedure provides information about the physiology or function of an organ?
1. Angiography
2. Computerized tomography (CT)
3. Magnetic resonance imaging (MRI)
4. Positron emission tomography (PET)
- Answer: 4. 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. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 34-9.
When assisting with a bone marrow biopsy, the nurse should take which action?
1. Assist the client to a right side-lying position after the procedure.
2. Observe for signs of dyspnea, pallor, and coughing.
3. Assess for bleeding and hematoma formation for several days after the procedure.
4. Stand in front of the client and support the back of the neck and knees.
- Answer: 3. 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. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 34-10.
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.
1. Alanine aminotransferase (ALT)
2. Myoglobin
3. Cholesterol
4. Ammonia
5. Brain natriuretic peptide or B-type natriuretic peptide (BNP)
- Answer: 1 and 4. Rationale: 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. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 34-2.
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?
1. Fasting blood glucose
2. Capillary blood specimen
3. Glycosylated hemoglobin
4. GGT (gamma-glutamyl transferase)
- Answer: 3. Rationale: 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. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 34-2.
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.
1. Mixes the reagent with the stool sample before applying to the card.
2. Collects a sample from two different areas of the stool specimen.
3. Assesses for a blue color change. 4. Asks a colleague to verify the pink color results.
5. Asks the client if he has taken vitamin C in the past few days.
- Answer: 2, 3, and 5. 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. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 34-5.
A primary care provider is going to perform a thoracentesis. The nurse’s role will include which action?
1. Place the client supine in the Trendelenburg position.
2. Position the client in a seated position with elbows on the overbed table.
3. Instruct the UAP to measure vital signs.
4. Administer an opioid analgesic.
- Answer: 2. Rationale: The puncture site is usually on the posterior chest. The client should be positioned leaning forward. This will allow the ribs to separate for exposure of the site. Option 1 is incorrect. The client should not be placed in the Trendelenburg position because the site would not be exposed. Option 3 is incorrect since changes in vital signs do not routinely occur with this procedure. Option 4 is incorrect. The client does not need to be medicated for pain with this procedure. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 34-10.
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.
1. Collect the specimen in the evening.
2. Send the specimen immediately to the laboratory.
3. Ask the client to spit into the sputum container.
4. Offer mouth care before and after collection of the sputum specimen.
5. Collect a specimen for 3 consecutive days.
- Answer: 2, 4, and 5. Rationale: The sputum specimen should be sent immediately to the laboratory. The client should be provided mouth care before and after the specimen is collected. The sputum specimen should be collected for three consecutive days. Option 1 is incorrect because the sputum specimen is collected in the morning not in the evening. Option 3 is incorrect because the term spit indicates that saliva is being examined. The client needs to cough up or expectorate mucus or sputum. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 34-7.
