Chap 34: Diagnostic
A client returns to the nursing unit after undergoing an esophagogastroduodenoscopy (EGD). Which is the appropriate nursing intervention? a. Allow the client to have bathroom privileges. b. Keep the client lying flat in bed in the supine position. C. Withhold oral fluids until the client's gag reflex has returned. d. Tell the client to report a sore throat immediately because it is a serious complication.
C. Withhold oral fluids until the client's gag reflex has returned. In preparation for the passage of the endoscope, an anesthetic is sprayed to inactivate the gag reflex and thus facilitate passage of the tube. It may take 1 to 2 hours for the anesthetic spray to wear off and for the gag reflex to return. The client would remain on bed rest in a semi-Fowler's position until fully alert. A sore throat is expected because of the endoscopic tube.
The clinic nurse has provided instructions to a client who will be reporting to the laboratory the next morning to have blood drawn for a complete blood cell count. Which statement made by the client indicates an understanding of the preparation for this laboratory test? a. "There is no special preparation for this test." b. "I cannot eat or drink anything after midnight." c. "I need to avoid any cold cuts and luncheon meats for the rest of the day." d. "I can drink coffee or tea in the morning before the test but cannot eat anything."
a. "There is no special preparation for this test." For most hematological laboratory studies, including complete blood cell count, no special care is needed either before or after the test. There is no reason to fast after midnight or avoid luncheon meats or cold cuts before the laboratory test being drawn.
The nurse is explaining to a client what electroencephalography (EEG) involves. What response by the client indicates that further teaching is needed? a. "This test is minimally invasive." b. "There is no risk of electric shock." c. "It can help diagnose and treat my seizures." d. "Electrodes are placed on specific areas of my scalp."
a. "This test is minimally invasive."
The nurse is explaining to an older client about a creatinine clearance test that has been prescribed. What response by the client indicates that there is a need for further teaching? a. "This test measures the levels of all of the medications that I take." b. "The doctor has to do tests on my kidneys to see how they are filtering." c. "In older clients, changes in the kidneys lead to less blood flow to the kidneys." d. "With aging, the kidneys don't clear all of my medications, so I can get very ill."
a. "This test measures the levels of all of the medications that I take." A creatinine clearance test does not measure levels of a client's medications but measures the glomerular filtration rate of the kidneys and how effectively the kidneys can eliminate substances. The other options are accurate statements.
The nurse is caring for a patient who is scheduled for a needle aspiration and biopsy to rule out cancer. Which Nursing diagnosis is appropriate and important for this patient? a. Anxiety related to potential for cancer diagnosis depending on biopsy results b. Impaired health maintenance related to delayed insurance coverage for procedure c. Powerlessness related to lengthy wait for diagnosis d. Ineffective coping related to patient stated she is a little nervous about the test results.
a. Anxiety related to potential for cancer diagnosis depending on biopsy results Fear is an emotion commonly experienced by patients waiting for diagnostic tests and biopsy results. Impaired health maintenance related to delayed insurance coverage is not a priority diagnosis for this patient at this time. Powerlessness is about the patient's ability to control an outcome and is not related to the wait for test results. The patient statement of feeling a little nervous about the test results is not indicative of ineffective coping.
A clinic nurse is providing instructions to a client regarding the procedure for collecting a midstream (clean-catch) urine specimen. What would the nurse instruct the client to do? a. Begin the flow of urine and then collect the specimen. b. Cleanse the perineum from back to front before collecting the specimen. c. Collect the specimen in the evening before going to bed, and deliver it to the laboratory immediately the next morning. d. Scrub the perineum with povidone-iodine solution in the evening and again in the morning before collecting the specimen.
a. Begin the flow of urine and then collect the specimen. The client would briefly delay collecting the sample until after starting the flow of urine. As part of the correct procedure, the client would cleanse the perineum from front to back with the antiseptic swabs that are packaged with the specimen kit to prevent contamination of the specimen. The specimen needs to be sent to the laboratory as soon as possible and not allowed to stand. Improper specimen handling can yield inaccurate test results. The client is not instructed to scrub the perineum with povidone-iodine solution in the evening and again in the morning before collecting the specimen. This action is unnecessary and can cause irritation.
The nurse is caring for a patient who has a deep leg wound that is badly infected. Which laboratory test results will the nurse expect to find in the patient's chart? a. Elevated C-reactive protein (CRP) 6.5 mg/dL b. Decreased serum creatinine 0.8 mg/dL c. Elevated serum bilirubin 0.5 mg/dL d. Prothrombin time (PT) 11.5 sec
a. Elevated C-reactive protein (CRP) 6.5 mg/dL C-reactive protein (CRP) is produced by the liver in response to inflammation, tissue damage, and infection. Blood levels of CRP have been used as a marker for inflammatory and autoimmune disorders. The nurse would expect to see an elevated CRP in a patient with an infected wound. Creatinine is an indicator of kidney function, and bilirubin is an indicator of liver function. Prothrombin time indicates clotting ability of the blood, particularly when the patient is taking warfarin (Coumadin).
The nurse is caring for a patient who has had severe acid reflux. Which test will allow the physician to directly check for damage to the esophagus? a. Esophagogastroduodenoscopy (EGD) b. MRI scan with contrast c. Abdominal ultrasound d. Positron emission tomography (PET) scan
a. Esophagogastroduodenoscopy (EGD) EGD is performed using a lighted tube that allows for direct visualization of the esophagus, stomach, and upper duodenum. MRI, ultrasound, and PET scanning do not allow physicians to see the esophagus directly.
The nurse is caring for a patient who has diabetes. The patient reports compliance with the medical regime. Which test result indicates to the nurse that the patient has not been compliant with the treatment plan? a. Hemoglobin A1c 16% b. Random blood sugar (RBS) 112 mg/dL c. Lactate dehydrogenase (LDH) 55 units/L d. Erythrocyte sedimentation rate (ESR) 14 mm/hr
a. Hemoglobin A1c 16% Hemoglobin A1c (Hgb A1c), or glycosylated hemoglobin, testing evaluates blood sugar levels over a period of 2 to 3 months This blood test is performed to provide the primary care provider (PCP) with information about long-term blood sugar control. The normal value of Hgb A1c in patients without diabetes is 4% to 5.9%. The American Diabetes Association (2016) states that diabetes is diagnosed for Hgb A1c levels greater than 6.5%. A higher level indicates that the patient has had poor blood glucose control during the past few weeks, and increases the patient's risk of long-term complications from hyperglycemia. The other tests are not related to long-term diabetes control.
The nurse is caring for a patient who needs to collect a 24-hour urine specimen at home. Which steps of specimen collection may be delegated to the assistant? (Select all that apply.) a. Label the urine container and lab slips with the patient's name and information. b. Assess the patient's ability to collect the specimen as required. c. Explain the procedure to the patient. d. Obtain the urine container from the utility room or laboratory. e. Transport the specimen to the laboratory once it is collected. f. Ensure that the correct test is ordered and collected.
a. Label the urine container and lab slips with the patient's name and information. d. Obtain the urine container from the utility room or laboratory. e. Transport the specimen to the laboratory once it is collected. The assistant may label the container and lab slips, obtain the urine container from the utility room, and transport the specimen to the lab. These are tasks that do not require nursing judgment. Assessment of the patient is always done by the nurse, as well as explaining the procedure to the patient and ensuring that the correct test is performed.
The nurse is caring for a patient who is undergoing a liver biopsy. Which interventions will be included in the patient's care plan for the diagnosis of risk for infection: r/t invasive diagnostic procedure? (Select all that apply.) a. Monitor for and report redness, warmth, discharge, or fever promptly to the physician. b. Carefully maintain the sterile field during the biopsy procedure. c. Teach patient how to care for the biopsy site when procedure is completed. d. Provide a supportive, caring presence to minimize patient anxiety. e. Provide information about the pathophysiology and treatment options for liver cancer. f. Consider using healing touch and other mind-body-spirit interventions.
a. Monitor for and report redness, warmth, discharge, or fever promptly to the physician. b. Carefully maintain the sterile field during the biopsy procedure. c. Teach patient how to care for the biopsy site when procedure is completed. Interventions for the Nursing diagnosis of risk for infection involve monitoring for signs and symptoms of infection, preventing contamination of supplies by maintaining a sterile field during the procedure, and teaching the patient how to care for the site afterward. Providing a caring presence, providing information about liver cancer, and using healing touch may be helpful for the patient but will not minimize the risk of infection.
The nurse is caring for a woman who has a cyst in her breast that was found at her recent mammogram. The physician wants to make sure that the cyst is not malignant. Which test will be used to determine this? a. Needle aspiration with biopsy b. Paracentesis c. Thoracentesis d. Fiberoptic endoscopy
a. Needle aspiration with biopsy Needle aspirations are procedures that are used to remove fluid and tissue for testing. A biopsy involves removing a larger collection of cells, as in a tumor or mass, and may be used to detect cancer in the skin, breast, or liver. Paracentesis is drainage of fluid from the abdomen, and thoracentesis is drainage of fluid from the pleural cavity. Fiberoptic endoscopy allows the physician to see inside the upper and/or lower GI tract.
The nurse is caring for a patient who will be undergoing flexible sigmoidoscopy testing to screen for colon cancer. What goal will the nurse include in the patient's plan of care? a. Patient will verbalize understanding of preprocedure preparation to be completed at home the day before the test. b. Patient will feel comfortable about the upcoming test and have trust in the health care providers. c. Patient will learn common side effects of the medications used to prepare the GI tract for endoscopy testing. d. Patient will realize how important regular sigmoidoscopy testing is in the prevention of colon cancer.
a. Patient will verbalize understanding of preprocedure preparation to be completed at home the day before the test. The patient will need to complete colon preparation prior to the sigmoidoscopy testing. The nurse must determine that the patient understands how and when to complete the prep. Having the patient verbalize understanding of the prep procedure is an objective goal so that the nurse can readily determine whether or not it has been met. The other goals are not objective or measurable, so the nurse cannot determine whether or not they have been met.
The nurse is caring for a patient who is anemic. Which CBC test results demonstrate that the patient's treatment plan is effective and the anemia is resolving? (Select all that apply.) a. Red blood cell count (RBC) 5.8 million/mm3 b. Hematocrit (HCT) 25% c. Hemoglobin (HGB) 14 g/dL d. White blood cell count (WBC) 4500/mm3 e. Platelet count (PLT) 255,000/mm3
a. Red blood cell count (RBC) 5.8 million/mm3 c. Hemoglobin (HGB) 14 g/dL Red blood cell count of 5.8 million and hemoglobin value of 14 g/dL are both normal. Hematocrit level of 25% is very low and indicative of ongoing anemia. White blood cell and platelet counts are not checked for anemia.
The nurse is caring for a patient who is to have a noncontrast MRI scan performed. Which assessment finding leads the nurse to report that the patient may not be able to have the test? a. The patient has an implanted insulin pump. b. The patient is breastfeeding her newborn infant. c. The patient is severely allergic to iodine and latex. d. The patient has profound hearing loss.
a. The patient has an implanted insulin pump. Any metal implants are a contraindication for an MRI scan because the scan uses powerful magnets. Insulin pumps often contain metal that can react with the strong magnets in the MRI machine. Breastfeeding is not a contraindication to MRI because there is no radiation exposure. No latex or iodine is used during MRI testing. Profound hearing loss will not be a problem, although MRI scanning is very loud.
A stool for culture needs to be obtained from a client suspected of having Clostridium difficile infection. What steps would the nurse plan to implement when obtaining the specimen? Select all that apply. a. Wearing sterile gloves b. Using a sterile container c. Refrigerating the specimen d. Sending the specimen directly to the laboratory e. Positioning the client in a dorsal recumbent position
a. Wearing sterile gloves b. Using a sterile container d. Sending the specimen directly to the laboratory A stool smear specimen is obtained using sterile gloves and a sterile container. After obtaining the specimen, the stool is sent immediately to the laboratory. Storing a stool specimen for culture in a refrigerator is contraindicated because it can retard the growth of organisms. The client needs to be positioned in a lateral recumbent position to obtain the sample.
The primary health care provider (PHCP) tells a client that a blood transfusion is needed and that a blood sample must be drawn first for blood typing and crossmatching. The nurse explains to the client what a typing and crossmatch test is for and why it is done. What response by the client about blood typing implies to the nurse that further teaching is needed? a. "It is an antigen found on the surface of the red blood cell." b. "It is an antibody found on the surface of the red blood cell." c. "An acute transfusion reaction can happen if I get blood incompatible with mine." d. "If I have group AB blood, I'm a universal recipient because I have no antibodies to react to the transfused blood."
b. "It is an antibody found on the surface of the red blood cell." The major blood types are A, B, AB, and O. The blood type indicates an antigen, not an antibody, found on the surface of the red blood cell. The other responses are accurate statements.
The ambulatory care nurse is providing instructions to a client who is scheduled for a colonoscopy and possible removal of a polyp. Which instructions are appropriate for client preparation for this procedure? a. Clear liquids may be consumed starting 24 hours after the procedure. b. A bowel preparation will be needed in preparation for the procedure. c. Clear liquids only are allowed on the day of the scheduled procedure. d. If blood-tinged stools are noted after the procedure, the primary health care provider needs to be notified.
b. A bowel preparation will be needed in preparation for the procedure. The client needs to be instructed that bowel preparation with a laxative is prescribed before the procedure to cleanse the bowel. Oral intake is allowed after the procedure once the client is stable. A clear liquid diet is permitted on the day before the procedure (per primary health care provider preference), and then oral intake is avoided for 8 hours immediately before the procedure. If a polyp has been removed, the client is instructed that the stool may be tinged with blood. However, any signs of tenderness, abdominal pain, or bloody stools need to be reported to the primary health care provider.
The nurse is assessing a client with chronic obstructive pulmonary disease. With a finger sensor, the nurse measures the client's oxygen saturation with a pulse oximeter machine and obtains a reading of 78% while the client is on oxygen via nasal cannula at 2 L/min. The client is showing no signs of restlessness or dyspnea. What is the first nursing action? a. Increase the client's oxygen to 4 L/min. b. Check the finger sensor's position and repeat the test. c. Notify the client's primary health care provider (PHCP) about the low reading. d. Check the client's chart to find out what the previous readings have been.
b. Check the finger sensor's position and repeat the test. Note that the low reading does not match the client's signs and symptoms. The first action by the nurse is to ensure that the test was done properly and the reading is accurate. The nurse would not increase the oxygen without a PHCP's prescription. The results of the test would be verified before any other actions are taken, and this can be done quickly.
The nurse is caring for a patient who has just undergone bronchoscopy. The patient requests a drink of water. What is the nurse's best action? a. Provide ice chips. b. Check the patient for a gag reflex. c. Provide a small cup of ice water with a straw. d. Keep the patient NPO.
b. Check the patient for a gag reflex. Numbing medication is applied to the back of the throat just before bronchoscopy. This may lead to swallowing difficulty and risk for aspiration until the gag reflex returns. The nurse should keep patient NPO until swallow, gag, and cough reflexes have returned. The nurse does not need to keep the patient NPO after the gag reflex returns so it should be checked in order to allow the patient to have fluids as soon as possible to relieve thirst.
The nurse is caring for a patient with a urinary tract infection. Which test will indicate which antibiotics will be effective to treat the infection? a. Complete blood count (CBC) b. Culture and sensitivity (C&S) c. Renal scan and angiography d. Radioreceptor assay for HCG
b. Culture and sensitivity (C&S) Culture and sensitivity are performed on specimens to determine which bacteria are causing the infection and which antibiotics will be effective treatment. CBC, renal scan, and radioreceptor assay for HCG will not indicate which antibiotics may be used to treat an infection
The nurse working in a same-day procedure unit is admitting a client scheduled for an arthrogram using a contrast medium. Which is the priority nursing assessment for this client? a. Determine if the client understands the procedure. b. Determine if the client has an allergy to iodine or shellfish. c. Determine if the client wishes to void before the procedure. d. Determine if the client is able to remain still during the procedure.
b. Determine if the client has an allergy to iodine or shellfish. Because of the risk of allergy to contrast medium, the nurse places highest priority on identifying an allergy to iodine or shellfish because allergic reaction as severe as anaphylaxis could occur. The nurse also would assess knowledge of the procedure, whether the client needs to void beforehand, and the ability to remain still during the procedure. Although all of these assessments may be made, the one with the highest priority is prevention of an allergic reaction through complete assessment.
The nurse is caring for a patient with diabetes who will be doing fingerstick blood glucose testing at home. What is the best way for the nurse to ensure that the patient can perform the procedure correctly? a. Quiz the patient on the steps of the procedure. b. Have the patient perform the procedure in front of the nurse. c. Ask the patient if he has any questions about the test. d. Use terminology that the patient can easily understand.
b. Have the patient perform the procedure in front of the nurse. Having the patient successfully perform the procedure in front of the nurse is an excellent way for the nurse to ensure that the patient knows how to do it correctly. Quizzing the patient about the procedure, asking the patient if he/she has questions, and using understandable terminology are fine, but only a return demonstration will assess the patient's ability to perform the procedure successfully and correctly.
A client with exacerbation of heart failure is being prepared for a thoracentesis. The nurse would assist the client to which position for the procedure? a. Lying in bed on the affected side b. Lying in bed on the unaffected side c. Left lateral recumbent position with the head of the bed flat d. Prone with the head turned to the side and supported by a pillow
b. Lying in bed on the unaffected side To facilitate removal of fluid from the chest, the client is positioned sitting at the edge of the bed leaning over the bedside table, with the feet supported on a stool; or lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. The prone and left lateral recumbent positions are inappropriate positions for this procedure.
The nurse is caring for a patient who is sedated following a colonoscopy. Which is the priority action of the nurse? a. Provide a quiet, dark environment so that the patient can rest comfortably. b. Monitor the patient's pulse oximetry and respirations closely. c. Inform the patient that the procedure has been completed. d. Assess the patient's bowel sounds and passage of flatus.
b. Monitor the patient's pulse oximetry and respirations closely. The priority intervention for sedated patients is to monitor pulse oximetry and respirations closely because sedation may suppress the respiratory drive. The nurse should monitor vital signs until the patient is fully awake and observe stools for visible blood. The nurse should also instruct the patient to report any abdominal pain as these assessment findings are alerts for possible perforation of bowel, hypotension, and hemorrhage. Providing a quiet environment is nice for the patient, but dim lighting may impair the nurse's ability to assess the patient. Informing the patient that the procedure has been completed is not a priority. Assessing the patient's bowel sounds and passage of flatus is not as important as careful respiratory monitoring.
A magnetic resonance imaging (MRI) study is prescribed for a client with a suspected brain tumor. Which priority action would the nurse include in the client's plan of care to ensure safety? a. Shave the groin for insertion of a femoral catheter. b. Remove all metal-containing objects from the client. c. Inform the client to remain motionless throughout the procedure. D. Instruct the client in inhalation techniques for the administration of the radioisotope.
b. Remove all metal-containing objects from the client. In MRI, radiofrequency pulses in a magnetic field are converted into pictures. All metal objects, such as rings, bracelets, hairpins, and watches, need to be removed. In addition, a history needs be taken to ascertain whether the client has any internal metallic devices such as orthopedic hardware, pacemakers, or shrapnel. Insertion of a femoral catheter is not part of the procedure. The client needs to be motionless throughout the procedure for quality of the scan, but this action is not related to a safety issue and therefore is not the priority. A radioisotope may be prescribed with positron emission tomography.
The nurse is caring for a client with a peptic ulcer who has just undergone an esophagogastroduodenoscopy (EGD). Which client problem would be the priority? a. Risk for dehydration caused by bleeding in the gastrointestinal tract b. Risk for choking and aspiration related to a poor gag reflex postprocedure c. Lack of knowledge of postprocedure care related to not having had an EGD before d. Sore throat related to passage of the endoscope through the pharyngeal region during EGD
b. Risk for choking and aspiration related to a poor gag reflex postprocedure EGD is a visual inspection of the esophagus, stomach, and duodenum using a fiber-optic endoscope. All the client problems listed as options are potentially appropriate for a client who just had an EGD. After the procedure, the client is recovering from the use of conscious sedation and the administration of a local anesthetic to the throat. Therefore, the client problem in option 2 is most important at this point because of the potential for airway problems.
The nurse is caring for a patient who recently had a liver biopsy. To whom must the nurse give the results? a. The patient b. The patient's health care provider c. The patient's insurance provider d. The patient's spouse
b. The patient's health care provider HIPAA protects the patient by requiring that testing results be shared only with health care professionals who need the information to provide treatment and with individuals designated in writing by the patient. The patient's provider will need the biopsy results to determine the patient's plan of care. The nurse does not give test results to the insurance company. The nurse may share the results with the patient or spouse, but it is not required, unless designated by the patient in writing.
The nurse is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. The nurse plans to implement which intervention to obtain the specimen? a. Ask the client to obtain the specimen after breakfast. b. Use a sterile plastic container for obtaining the specimen. c. Provide tissues for expectoration and obtaining the specimen. d. Ask the client to expectorate a small amount of sputum into the emesis basin.
b. Use a sterile plastic container for obtaining the specimen. Sputum specimens for culture and sensitivity testing need to be obtained using sterile technique because the test is done to determine the presence of organisms. If the procedure for obtaining the specimen is not sterile, the specimen will be contaminated, and the results of the test will be invalid. A first-morning specimen is preferred because it contains overnight secretions from the tracheobronchial tree.
The nurse is providing information to a client about a computed tomography (CT) scan of the head. Which statement would the nurse include when reviewing preparation for the CT with the client? a. "You will need to stand up straight for the entire procedure." b. "All scans require the injection of dye before the procedure." c. "Each set of head scans takes less than 5 minutes to perform." d. "You will need to remain on bed rest for 12 hours after the scan."
c. "Each set of head scans takes less than 5 minutes to perform." For a CT scan of the head, the client lies on a movable table in a head-holding device. Each set of head scans takes less than 5 minutes to perform. An iodinated contrast medium may or may not be used. No special aftercare is indicated, so the client may resume the usual diet and activity afterward.
A client is being scheduled for a positron emission tomography (PET) scan of the brain. The nurse would provide which explanation to the client? A. "The test uses magnetic fields to produce images." b. "The test provides cross-sectional views of the brain." c. "The test detects abnormal glucose metabolism in the brain." d. "The test views bones of the skull, nasal sinuses, and vertebrae."
c. "The test detects abnormal glucose metabolism in the brain." The PET scan can detect abnormal brain tissue metabolism. A radionuclide is attached to a glucose component and is injected as an intravenous bolus. The computer records the chemical activity in the brain following injection. Options 1, 2, and 4 describe magnetic resonance imaging (MRI), computed tomography (CT), and radiography, respectively.
The nurse is providing directions to a client about how to test a stool for occult blood. The nurse cautions the client that which could cause a false-negative result? a. Iodine b. Colchicine c. Ascorbic acid d. Acetylsalicylic acid
c. Ascorbic acid Ascorbic acid can interfere with results of occult blood testing, yielding a false-negative result. Colchicine and iodine can cause false-positive results. Acetylsalicylic acid would have no effect or could cause a positive result by inducing bleeding from the gastrointestinal tract.
A computed tomography scan of the chest with contrast is scheduled to be performed in a client suspected of having a pulmonary embolism. In planning the preprocedure care for this client, which nursing action is necessary? a. Encourage intake of fluids. b. Shave the anticipated entry site. c. Ask the client about allergies and previous reactions. d. Contact the operating room regarding the need for the procedure.
c. Ask the client about allergies and previous reactions. A computed tomography scan is not performed in the operating room; therefore, it is not necessary that the nurse contact this department. There is no surgical entry site; therefore, shaving is unnecessary. The procedure is explained to the client, who also is asked about allergies to shellfish or contrast media. Oral ingestion except for sips of water is avoided for 4 to 6 hours before the test.
The nurse has a prescription to collect a 24-hour urine specimen from a client. The nurse is demonstrating correct procedure when which technique is performed? a. Ask the client to void, save the specimen, and note the start time. b. Place the specimen in various containers as necessary for the test. c. Ask the client to save a sample voided at the end of the collection time. D. Remove urine from the collection container for other prescribed specimens.
c. Ask the client to save a sample voided at the end of the collection time. Because the 24-hour urine test is a timed quantitative determination, the test must be started with an empty bladder; therefore, the first urine is discarded. Fifteen minutes before the end of the collection time, the client would be asked to void, and this specimen is added to the collection. The urine sample needs to be placed in the appropriate container and may be refrigerated or placed on ice to prevent changes in the urine. Because this is a quantitative determination of constituents in the urine, no urine would be removed from the container.
The nurse is developing a plan of care for a client who has undergone an esophagogastroduodenoscopy procedure. The nurse would include which intervention in the nursing care plan? a. Monitor the client's vital signs every hour for 4 hours. b. Place the client in a prone position to provide comfort. c. Ensure that a gag reflex is present before allowing the client any oral intake. d. Provide saline gargles immediately on the client's return to the nursing unit to aid in comfort
c. Ensure that a gag reflex is present before allowing the client any oral intake. After esophagogastroduodenoscopy (EGD), the vital signs are checked frequently, usually every 30 minutes, until sedation wears off. The nurse places the client in a semi-Fowler's to Fowler's position to aid in comfort and prevent aspiration. The client remains on NPO (nothing by mouth) status until the gag reflex returns (usually in 2 to 4 hours). The nurse can check the gag reflex by using a tongue depressor to stroke the back of client's throat. Saline gargles would not be allowed until the gag reflex returns.
The client with lung cancer and a right-sided pleural effusion seen on chest x-ray is being prepared for a thoracentesis. The nurse would assist the client to which position for the procedure? a. Supine position, with the head of the bed flat b. Prone, with the head turned to the side supported by a pillow c. Left side-lying position, with the head of the bed elevated 45 degrees d. Right side-lying position, with the head of the bed elevated 45 degrees
c. Left side-lying position, with the head of the bed elevated 45 degrees To facilitate removal of fluid from the pleural space, two positions may be used. The client may be positioned sitting on the edge of the bed, leaning over the bedside table, with the feet supported on a stool. The other position is lying in bed on the unaffected side, with the head of the bed elevated 45 degrees (Fowler's position). The other options are incorrect because they do not facilitate drainage of fluid to an area easily removed with thoracentesis.
The nurse is providing instructions to the client with lung cancer scheduled for magnetic resonance imaging who is suspected of brain metastasis. Which instruction would the nurse provide to the client? a. Injection of a dye is necessary. b. Food and fluids are restricted for 12 to 24 hours before the test. c. Lying still in a flat position for 45 to 60 minutes may be necessary. d. The test may cause some pain, and pain medication will be prescribed if pain occurs.
c. Lying still in a flat position for 45 to 60 minutes may be necessary. The client will need to lie in a flat position for 45 to 60 minutes. The client is informed that magnetic resonance imaging (MRI) is a painless test and that a contrast dye may or may not be used. Additionally, no dietary restrictions are necessary with MRI. The nurse informs the client that the MRI may damage items such as credit cards and watches and that jewelry and hair clips cause artifacts. These objects need to be removed from the client before the test.
The nurse is assisting the primary health care provider during a colonoscopy procedure. The nurse helps the client to assume which best position for the procedure? a. Supine b. Lithotomy c. Modified left lateral d. Modified right lateral
c. Modified left lateral The client is placed in the modified left lateral position for the procedure. This position uses the client's anatomy to the best advantage for introducing the colonoscope. The modified left lateral position would also be used for giving the client an enema while lying down. Therefore, options 1, 2, and 4 are incorrect.
The nurse is caring for a patient who is having blood drawn as part of preoperative testing. Which step is the most important to ensure the safety of the patient and the nurse? a. Ensuring that the tourniquet is not left in place for too long b. Using the smallest possible needle for venipuncture c. Properly disposing of the needle after the specimen is obtained d. Making sure that all of the collection tubes are filled completely
c. Properly disposing of the needle after the specimen is obtained Proper disposal of needles and sharps after procedures is essential for safe nursing practice to ensure the safety of staff as well as patients. Ensuring that the tourniquet is not left on too long, using the smallest needle possible, and making sure that all of the vials are filled are important steps in venipuncture, but only proper sharps disposal will help ensure the safety of the patient and the nurse.
The nurse is caring for a patient who has a bleeding gastric ulcer. How will the nurse expect the patient's stool to appear? a. Soft and formed with bright red streaks b. Watery with particles of undigested food c. Sticky and black d. Hard lumps that are difficult to pass
c. Sticky and black Bleeding anywhere along the GI tract results in blood in the stool. Bleeding that occurs in the upper GI tract produces stools that are black and tarry in appearance. Bleeding within the lower GI tract presents with soft stools that have bright red streaks. Watery stool with particles of food is indicative of gastroenteritis. Hard lumps that are difficult to pass indicate constipation, often from medications or lack of fiber in the diet.
The nurse provides instructions to a client who is scheduled for an electroencephalogram. Which statement by the client indicates a need for further instruction? a. "The test will take between 45 minutes and 2 hours." b. "My hair needs to be washed the evening before the test." c. "Cola, tea, and coffee are restricted on the day of the test." d. "All medications need to be withheld on the day of the test."
d. "All medications need to be withheld on the day of the test." The client is informed that the test will take 45 minutes to 2 hours and that medications usually are not withheld before the test unless specifically prescribed. Preprocedural instructions include informing the client that the procedure is painless. Cola, tea, and coffee are stimulants and need to be restricted on the morning of the test. The hair needs to be washed the evening before the test, and gels, hair sprays, and lotion would be avoided.
The nurse instructs a client suspected of having a urinary tract infection to obtain a clean-catch urine specimen for culture and sensitivity testing. Which statement by the client indicates that the client understands the procedure for collecting the specimen? a. "A urine specimen will be obtained from a catheter." b. "I need to clean the labia with toilet paper and void into the sterile specimen container." c. "I need to empty my bladder into a container so that the full amount of urine can be determined." d. "I need to cleanse the labia using cleansing towels, void into the toilet, and then void into the sterile specimen container."
d. "I need to cleanse the labia using cleansing towels, void into the toilet, and then void into the sterile specimen container." Urine specimens for culture and sensitivity need to be obtained with the use of proper cleansing and voiding techniques to avoid contamination from external sources. The use of toilet paper will contaminate the specimen. The procedure described in option 3 would not provide a clean specimen. It is not necessary to obtain the specimen via a catheter.
The nurse is caring for a patient who is to collect a 24-hour urine specimen. Which statement by the patient indicates that additional teaching is required? a. "I will keep the urine container on ice to keep it chilled until I bring it to the lab." b. "I will start the test over if I forget and urinate into the toilet during the testing time." c. "I will start the test tomorrow after I urinate first thing in the morning." d. "I will drink extra fluids so that the lab will have a large specimen to test."
d. "I will drink extra fluids so that the lab will have a large specimen to test." Drinking extra fluids so that the lab will have an extra-large specimen to test is not done as part of 24-hour urine collection, and it may skew the test results. The specimen should be kept chilled on ice or in a refrigerator until it is brought to the lab. If the patient accidentally urinates in the toilet, the test must be started over again. Urine collection is started after the patient's first void of the morning into the toilet.
A young adult client has never had a chest x-ray before and expresses to the nurse a fear of experiencing some form of harm from the test. Which statement by the nurse provides valid reassurance to the client? a. "You'll wear a lead shield to partially protect your organs from harm." b. "The amount of x-ray exposure is not sufficient to cause DNA damage." c. "The test isn't harmful at all. The most frustrating part is the long wait in radiology." d. "The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation."
d. "The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation." Clients would be taught that the amount of exposure to radiation is minimal and that the test itself is painless. The wording in each of the other options is only partly true and therefore cannot provide valid reassurance to the client.
A client with type 2 diabetes mellitus presents to the primary health care provider's office with a glycosylated hemoglobin (HgbA1C) level of 10.5%. Which statement by the client indicates an understanding of this test and its results? a. "The results of the test are probably high because I ate a doughnut for breakfast this morning." b. "The results of the test are probably low because I had not eaten anything for 12 hours before my blood was drawn." c. "I know that I need to check my glycosylated hemoglobin before each meal and at bedtime, but I don't always do it. I will do it more regularly." d. "Well, I have 3 months to really work on watching my diet and lowering my blood sugar. My next glycosylated hemoglobin test will be better then."
d. "Well, I have 3 months to really work on watching my diet and lowering my blood sugar. My next glycosylated hemoglobin test will be better then." The HgbA1C test provides a measurement of glycemic control over the previous 2 to 3 months, with increases in the HgbA1C reflecting elevated blood glucose levels. An HgbA1C of less than 6% is recommended by most primary health care providers. Thus, option 4 is the correct answer. Options 1 and 2 are incorrect, as HgbA1C measures glycemic control over a few months, and thus having fasted for a long time or having just eaten something does not affect HgbA1C. Option 3 is incorrect because clients check their blood glucose levels, not their HgbA1C, before meals and at bedtime.
The clinic nurse is providing instructions to a client who is scheduled for a barium enema. What instruction would the nurse provide to the client in preparation for this procedure? a. Liquids are restricted for 24 hours after the test. b. A clear liquid diet is required for 4 days before the test. c. Laxatives would not be taken for at least 1 week before the test. d. A low-fiber diet needs to be maintained for 1 to 3 days before the test.
d. A low-fiber diet needs to be maintained for 1 to 3 days before the test. Preparation for a barium enema includes maintaining a low-fiber diet for 1 to 3 days before the test. Clear liquids or water may be allowed 12 to 24 hours before the test. Laxatives and enemas may be prescribed before the test to cleanse the bowel. The client is encouraged to drink liquids after the procedure to facilitate the passage of barium.
The nurse is caring for an elderly patient with dementia. Which laboratory finding indicates to the nurse that that patient is often forgetting to eat meals? a. Serum bilirubin 0.4 mg/dL b. PLT (platelet count) 425,000/mm3 c. Serum cholesterol 175 mg/dL d. Albumin 1.4 g/dL
d. Albumin 1.4 g/dL Albumin level is an indicator of the patient's protein intake and nutritional status. Normal albumin level is 3.3 to 5 g/dL. It is an essential component of fluid balance, responsible for maintaining colloidal oncotic pressure in the vascular and extravascular spaces. Low levels of albumin may indicate malnutrition.
A client suspected of having a duodenal ulcer has undergone esophagogastroduodenoscopy. The nurse would place highest priority on which item as part of the client's care plan? a. Monitoring the temperature b. Monitoring complaints of heartburn c. Giving warm gargles for a sore throat d. Assessing for the return of the gag reflex
d. Assessing for the return of the gag reflex The nurse places highest priority on assessing for return of the gag reflex. This assessment addresses the client's airway. The nurse also monitors the client's vital signs and for a sudden increase in temperature, which could indicate perforation of the gastrointestinal tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client's airway is the priority.
The nurse is caring for a client with suspected kidney failure. A 24-hour urine specimen is prescribed. What value, which measures overall kidney function, will the nurse specifically plan to check? a. Sodium levels b. Protein levels c. Blood uric acid levels d. Creatinine clearance levels
d. Creatinine clearance levels Creatinine clearance is a calculated measure of glomerular filtration rate and is the best indication of overall kidney function. The amount of creatinine cleared from the blood (e.g., filtered into the urine) is measured in the total volume of urine excreted in a defined period. The analysis compares the urine creatinine level with the blood creatinine level; therefore, a blood specimen for creatinine must also be collected. Sodium levels are decreased in prerenal acute kidney injury. Increased levels of protein indicate glomerular disease, nephrotic syndrome, diabetic neuropathy, and urinary tract malignancies and irritations. Uric acid levels are increased in conditions such as gout or uric acid calculi.
A client has just returned to a nursing unit following bronchoscopy. Which nursing intervention would the nurse implement? a. Administering atropine intravenously b. Administering small doses of a sedative c. Encouraging additional fluids for the next 24 hours d. Ensuring the return of the gag reflex before offering food or fluids
d. Ensuring the return of the gag reflex before offering food or fluids After bronchoscopy, the nurse keeps the client on NPO (nothing by mouth) status until the gag reflex returns because the preoperative sedation and local anesthesia impair swallowing and the protective laryngeal reflexes for a number of hours. Additional fluids are unnecessary because no contrast dye is used that would need flushing from the system. Atropine and a sedative would be administered before the procedure, not after.
The nurse is caring for a patient who has just undergone paracentesis. For which complication will the nurse carefully monitor? a. Collapse of the lung with shortness of breath b. Fecal impaction from retained barium in the colon c. Cerebrospinal fluid leak resulting in severe headache d. Perforation of the bowel resulting in abdominal infection
d. Perforation of the bowel resulting in abdominal infection Paracentesis is drainage of fluid from the abdominal cavity. Since the needle is near the intestines, bowel perforation can occur, manifested by abdominal pain and fever as infection (peritonitis) sets in. Possible complications do not include lung collapse, CSF leak, or impaction.
The nurse is caring for a patient who will be receiving iodine-based contrast medium for a CT scan. Which allergy should be reported to the technician and radiologist before the test is performed? a. Gluten and lactose b. Strawberries and blueberries c. Peanuts and cashews d. Shrimp and scallops
d. Shrimp and scallops If the patient is undergoing an examination that involves an iodine contrast medium, check for a history of adverse reactions or allergies to iodine-containing food (e.g., shellfish, cabbage, kale, iodized salt). The other allergies are not related.
A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. How would the nurse describe this test to the client? a. The test may be painful. b. The test will take approximately 2 hours. c. Fluids will be restricted following the test. d. The dye injected may cause a warm, flushing sensation.
d. The dye injected may cause a warm, flushing sensation. CT scanning causes no pain and can take 15 to 60 minutes to perform. The dye may cause a warm, flushing sensation when injected. Fluids are encouraged following the procedure. If an iodine dye is used, the client would be asked about allergies to seafood or iodine.
A client recovering from cardiac surgery has a left pleural effusion and is about to undergo a thoracentesis. What position would the nurse place the client in for the procedure? a. Dorsal recumbent b. Left lateral, with the right arm supported by a pillow c. Right side-lying, with the legs curled up into a fetal position d. Upright and leaning forward with the arms on an over-the-bed table
d. Upright and leaning forward with the arms on an over-the-bed table The client undergoing thoracentesis usually sits in an upright position with the anterior thorax supported by pillows or leaning over an over-the-bed table. The client must be placed in a position that will enlist the aid of gravity in accessing and draining the effusion. The dorsal recumbent position is an inaccessible position. Any side-lying position will cause fluid to accumulate under that side, which is inaccessible to the primary health care provider. However, if the client cannot sit upright, the client will be placed in a side-lying position on the unaffected side, with the side to be tapped uppermost.