Lab Value,tests and nutrition
The nurse is preparing a client scheduled for a bone marrow aspiration, and the client asks the nurse whether the procedure will be painful. The nurse should make which response to the client?
"A local anesthetic will be given and will decrease the discomfort."
The nurse is reinforcing diet teaching for a client on a low-sodium diet for hypertension. The nurse determines that there is a need for further teaching when the client makes which statement?
"Canned foods are inexpensive and are good to use on a low-sodium diet."
The nurse reinforces instructions to a client who is to return to the primary health care provider's office in 1 week for a patch test to identify the allergen causing the dermatitis. The nurse provides which instruction to the client?
"Discontinue the prescribed antihistamine 2 days before the test."
A client being seen in a primary health care provider's office has just been scheduled for a barium swallow the next day. The nurse writes down which instructions for the client to follow before the test?
"Do not eat or drink after midnight tonight."
The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement?
"Fresh foods such as fruits and vegetables are high in sodium."
The nurse is planning to administer an oral glucose tolerance test (OGTT) to a client to rule out or confirm diabetes mellitus. The nurse knows that the client needs more information when the client makes which statements? Select all that apply.
"I can at least drink fluids during the test." 3."I have 30 minutes to drink the glucose load." "I will have blood drawn every 5 minutes for the next 3 hours."
A primary health care provider prescribes a 24-hour urine collection for vanillylmandelic acid (VMA). The nurse instructs the client in the procedure for the collection of the urine. Which statement by the client would indicate a need for further teaching?
"I can take any medications if I need to before the collection."
Which statement by the client should cause the nurse to suspect that the thyroid test results drawn on the client this morning may be inaccurate?
"I had a radionuclide test done 3 days ago."
The nurse has reinforced instructions to a client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that there is a need for further teaching if the client makes which statement?
"I hope the incision from the test will heal quickly."
Abdominal ultrasonography is prescribed for a client who is pregnant. The nurse provides information to the client regarding the procedure and makes which statement?
"You will be positioned on your back and turned slightly to one side with your head elevated."
A client has been admitted for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?
15 mg/dL
A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to which value?
15 mg/dL (5.25 mmol/L)
The nurse is reviewing the results of a client's serum laboratory studies. Which result indicates a deficiency of protein intake?
Albumin, 2.6 mg/dL
A client has had a bone scan procedure. The nurse determines that the client understands the elements of follow-up care if the client states which postprocedural care?
Drink plenty of water for a day or two following the procedure.
The nurse is reinforcing dietary instructions to a client with tuberculosis who has lost weight. The nurse reinforces instructions for the client to increase intake of protein and vitamin C. The nurse determines that teaching has been effective when the client selects which food items in the daily diet?
Hamburger and oranges
Which cardiovascular sign should the nurse expect to note in a client with a diagnosis of hypocalcemia?
Hypotension
A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse should take which action after seeing the laboratory results?
Place the normal report in the client's medical record.
The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food item?
Scallops
The nurse is instructing a client with osteomalacia about appropriate food items to include in the diet. Which food items should be included in the client's diet? Select all that apply.
milk salmon
The mother of an infant newly diagnosed with cystic fibrosis is being taught proper nutritional needs for the infant. The nurse determines that the mother understands nutritional needs when the mother gives which response?
"I know I need to monitor my infant's stools, and if there are more than four stools a day, I will increase the pancreatic enzyme."
A caregiver states that the client eats only about 25% of the food that is offered and is losing weight. The caregiver asks the nurse about feeding the client by a tube into the stomach. Which initial response by the nurse would be appropriate?
"Tube feedings can provide adequate amounts of required nutrients."
The nurse is reinforcing postprocedure teaching after a client underwent an upper gastrointestinal (GI) series. The nurse reminds the client that the stools will remain white for approximately how long?
1 to 2 days
Which laboratory results indicate a therapeutic drug level? Refer to chart. Select all that apply.
1,3.5
A client has been diagnosed as having syndrome of inappropriate antidiuretic hormone (SIADH) secretion following cranial surgery. The nurse interprets that this complication is not resolving if which urine specific gravity measurement is obtained?
1.030
The nurse who is assisting in a weight loss program prepares to monitor a client's weight. The client receives education about caloric intake and weight reduction. In order to lose 2 pounds per week the caloric intake should be decreased by how many calories per day?
1000 calories
A client with a history of seizure disorder is having a routine serum phenytoin level drawn. The nurse who receives a telephone report of the results notes that the client's blood level of the medication is within the normal range if which value is reported?
15 mcg/mL
A client has been treated for dehydration and pneumonia. The nurse evaluates that the client has been successfully treated if the blood urea nitrogen (BUN) level is which value?
19 mg/dL
The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would suggest to the registered nurse the need for implementing neutropenic precautions if the client's white blood cell count was which value?
2000 mm3 (2.0 × 109/L)
A client with diabetes mellitus has a blood sample drawn for the determination of a fasting blood glucose level. When reviewing the client's results, the nurse determines that which requires a call to the primary health care provider for intervention?
240 mg/dL (13.7 mmol/L)
A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide?
3.2 mEq/L (3.2 mmol/L)
The nurse is assigned to a hospitalized client with chronic pancreatitis. The nurse reviews the client's record and expects to note a serum amylase level that is most like which value?
300 units/L
A client is receiving an enteral feeding that delivers 1.5 calories/mL. The feeding is infusing at 30 mL/hr via a feeding pump. What is the maximal amount of calories the client should receive in an 8-hour period if the tube feeding is not interrupted? Fill in the blank.
360
The nurse is monitoring the laboratory results of a client preparing to receive chemotherapy. The nurse determines that the white blood cell count (WBC) is normal if which result is present?
5000 mm3 (5 × 109/L)
The nurse caring for a client with a neurological disorder is assisting in planning care to maintain nutritional status. The client has had a swallowing study done that shows the client is at risk for aspiration and is able to feed self. The nurse should review which interventions with the unlicensed assistive personnel (UAP)? Select all that apply.
Add the prescribed thickener to liquids. Observe client for episodes of coughing or choking.
A client is to have an upper gastrointestinal (GI) series. Which nursing action should be done concerning the procedure?
Administer a laxative after the procedure because barium was administered.
A client is scheduled for endoscopic retrograde cholangiopancreatography (ERCP). The nurse includes which intervention in the plan of care for the client?
After the procedure, keep the client nothing by mouth (NPO) until the gag reflex returns.
The nurse is caring for a client recovering from hepatitis. The nurse recognizes the need to report which laboratory test result to the primary health care provider?
Alanine aminotransferase (ALT) that is significantly elevated
A tuberculin skin test is administered to an individual infected with human immunodeficiency virus (HIV). Seventy-two hours later, the nurse checks the test site and documents the results as positive, indicating that the individual has been exposed to tuberculosis. Which findings did the nurse identify to make this interpretation?
An area of induration at the test site measuring 7 mm
A primary health care provider is caring for a client who is human immunodeficiency virus (HIV) positive and has delivered a newborn baby. The nurse anticipates which interventions should be employed for the newborn to decrease the risk of HIV. Select all that apply.
Antiretroviral prophylaxis for newborns testing HIV positive. 5.Periodic testing for HIV at set intervals until the age of 6 months. HIV testing of the newborn within 48 hours
A lethargic, pale child is brought to the primary health care provider's office with symptoms of periorbital edema and reduced quantity of urine output. The urine is cloudy and smoky in color. The nurse asks the mother if the child has had any recent infections, to which the mother responds that the child had a very sore throat a few weeks ago. The primary health care provider suspects that the child might have acute poststreptococcal glomerulonephritis. Which laboratory test would rule out a past streptococcal infection in the child?
Antistreptolysin titer
A child is receiving edetate calcium disodium (calcium EDTA) for the treatment of lead poisoning. Which laboratory result would be important to monitor during treatment?
Blood urea nitrogen (BUN) level
The nurse reinforces instructions regarding diet for a client at risk for hypokalemia. The nurse determines there is a need for further teaching when the client selects which foods as sources high in potassium? Select all that apply.
Bread and butter 2.Carrots and peas 3.Peppers and onions
A postoperative client has been placed on a clear liquid diet. Which items is the client allowed to consume? Select all that apply.
Broth 2.Coffee 3.Gelatin
A client has a prescription to take sodium polystyrene sulfonate for several days. The client also needs to make some dietary changes. Which foods should the client avoid? Select all that apply.
Cabbage Mushrooms 5.Strawberries
The nurse reviews the client's laboratory results. Which abnormal findings should the nurse report? Select all that apply.
Calcium 8.2 mg/dL 2.Potassium 6 mEq/L Magnesium 2.9 mg/dL 5.Phosphorus 5.2 mg/dL
A client states that he has removed all dairy foods from his diet because he is lactose intolerant. The nurse plans care for the client knowing which information?
Calcium and protein are valuable nutrients and need to be supplemented in some form.
The nurse reviews the client's laboratory data. Which data warrant notification of the registered nurse and an immediate call to the primary health care provider? Refer to chart.
Calcium level
The nurse is caring for a client following a total hip replacement. The client has been diagnosed with iron deficiency anemia. The nurse instructs the client to increase intake of which foods? Select all that apply.
Clams and mussels Lean beef and chicken liver
Which laboratory result would verify the diagnosis of bacterial meningitis?
Cloudy cerebrospinal fluid with high protein and low glucose levels
A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, should offer which items during an episode of nausea?
Cool, clear liquids
A client who has calcium phosphate kidney stones tells the nurse, "Tell me what I can do, so that I never have this pain again." Which instructions should the nurse plan to include in the reinforcement of dietary instructions? Select all that apply.
Decrease sodium intake. Limit the intake of whole grains. 5.Limit protein to 5 to 7 servings per week.
A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The primary health care provider inserts a nasogastric tube and prescribes a tube feeding of a standard formula feeding to run at 50 mL/hr. The nurse plans care, knowing that which is true regarding enteral feedings?
Enteral feedings require the normal digestive capabilities of the gastrointestinal (GI) tract.
A client undergoing diagnostic testing for cancer is scheduled for magnetic resonance imaging (MRI). The nurse reinforces to the client which information about the procedure?
Expect the MRI machine to make loud noises.
The nurse is reviewing the serum electrolyte laboratory results of a client and finds that the client has an elevated magnesium level. Which part of the client's history is likely associated with this problem?
History of chronic laxative use
A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription?
Holding the next dose of warfarin
The nurse is reinforcing preprocedure instructions to a client scheduled for a barium swallow at 8.00 am. Which statement by the client indicates a need for further teaching?
I will limit myself to two cigarettes only on the morning of the test.
A 17-year-old pregnant client is being seen at the obstetric clinic. The nurse is reviewing the following laboratory results, which were obtained 2 hours after breakfast: hemoglobin 10 g/dL (100 mmol/L), sodium 140 mEq (140 mmol/L), glucose 110 mg/dL (6 mmol/L), potassium 4.1 mEq (4.1 mmol/L). Which dietary instruction should the nurse reinforce for this client?
Increase the amount of red meats.
A client is admitted to the hospital with a diagnosis of suspected myocardial infarction (MI). The nurse is reviewing the laboratory results performed on the client. Which documented laboratory result specifically indicates the presence of an MI?
Increased creatine kinase (CK-MB)
The nurse is preparing a client for the administration of a tuberculin skin test. The nurse determines that which body areas are appropriate for intradermal injections? Select all that apply.
Inner aspect of the forearm Dorsal aspect of the upper arm 4.Away from heavy pigmentation
A client is complaining about pain when voiding. The primary health care provider prescribes a clean-catch urine specimen. The nurse should instruct the client to perform which action first when obtaining this specimen?
Instruct the client to wash her hands.
An adult female client has a hemoglobin level of 10.8 g/dL (108 g/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?
Iron deficiency anemia
A client is scheduled for a myelogram, and the nurse reinforces a list of instructions to the client regarding preparation for the procedure. Which instructions should the nurse include in the list? Select all that apply.
Jewelry will need to be removed. 2.An informed consent will need to be signed. Nonalcoholic fluid intake should be increased after the procedure.
The nurse teaches the family of an infant with spina bifida that the infant should not be given which baby foods that may trigger a latex-type food allergy? Select all that apply.
Kiw iBananas 5.Avocados
A client who has recently been started on enteral feedings begins to complain of abdominal cramping, followed by passage of two liquid stools. The nurse notes that the client has abdominal distention as well. The nurse reviews the nutritional content on the label of the can to see if it contains which ingredient?
Lactose
The nurse reinforces postoperative liver biopsy instructions to a client. Which should the nurse tell the client?
Lie on the right side for 2 hours.
A client with a tentative diagnosis of gastroesophageal reflux disease (GERD) is going to undergo ambulatory pH monitoring. The nurse assists in the procedure and should bring which item to the bedside?
Nasogastric (NG) tube
A licensed practical nurse (LPN) is assisting in the care of a client receiving a continuous intravenous (IV) infusion of heparin sodium for deep vein thrombosis (DVT). The LPN notes that the result of a newly drawn activated partial thromboplastin time (aPTT) level is 90 seconds. The client's baseline before the initiation of therapy was 30 seconds. The LPN should take which action?
Notify the RN about the value immediately.
A client receiving enteral feedings develops abdominal distention and diarrhea shortly after initiation of the feedings. Which is the appropriate intervention for the nurse to implement?
Notify the primary health care provider (PHCP) of the client's signs and symptoms.
A primary health care provider (PHCP) has written a prescription for a preoperative client to have "enemas until clear." The nurse has administered three enemas and the client is still passing brown liquid stool. Which action should the nurse take next?
Notify the primary health care provider.
A client who has been prescribed indomethacin for gout is asked to provide a stool sample for guaiac testing. The nurse explains that the purpose of the test is to make which determination?
Occult blood
The nurse employed in a well-baby clinic is reinforcing nutrition instructions to the mother of a 1-month-old infant. Which instruction should the nurse provide the mother?
Offer breast milk or formula as the main food.
The nurse has conducted dietary teaching with the client diagnosed with iron deficiency anemia. The nurse determines that the client understands the information if the client states the intention to increase intake of which foods? Select all that apply.
Oysters 2.Spinach Kidney beans
A gastric analysis is prescribed for a client with a suspected diagnosis of tuberculosis (TB). The nurse understands that the test is relevant in confirming this diagnosis because of which related fact?
People can frequently swallow small amounts of sputum.
A client with a history of seizure disorder is receiving phenytoin in the hospital. The client has a seizure and the nurse reviews the laboratory results of the phenytoin level of 18 mcg/mL. The therapeutic level is 10 to 20 mcg/mL. The nurse understands from reviewing the medication level that which is the correct situation?
Phenytoin alone is not effectively controlling seizures.
A client is receiving standard oral anticoagulant therapy with warfarin. The result of a newly drawn international normalized ratio is 3.8 seconds. The client needs to have an invasive procedure done on the next day. Which medication will likely be ordered to reverse the anticoagulant effect?
Phytonadione
The nurse is reading a client's urinalysis report. The nurse interprets which item found on the report to be considered abnormal? Select all that apply.
Positive protein Leukocyte esterase positive 6.White blood cells,10 per high power screen
An adult client has had serum electrolytes drawn. The nurse receiving the results by telephone from the laboratory should be most concerned with which result?
Potassium 5.4 mEq/L
The nurse is reviewing the laboratory results from the lumbar puncture performed on a client with a diagnosis of meningitis. Which findings are indicative of a bacterial infection? Select all that apply.
Protein level of 20 mg/dL 4.Increased white blood cells 5.A cerebrospinal fluid (CSF) pressure of 250 mm H2O
A client is scheduled for a digital subtraction angiography (DSA). The nurse tells the client that the test is directed toward which outcome?
Providing information about the blood vessels
A client has a serum sodium level of 151 mEq/L (151 mmol/L), and the nurse reinforces dietary teaching about the types of foods to avoid. The nurse determines that there is a need for further teaching if the client states that which food choices are good? Select all that apply.
Sauerkraut 6.American cheese
The nurse is assisting in monitoring a client who may be started on parenteral nutrition (PN). The nurse reviews the client's laboratory results and determines that the client is at risk of severe malnutrition if the report indicates which critical level?
Serum albumin 2.8 g/dL
A client receiving total parenteral nutrition (TPN) asks the nurse if he has developed diabetes when the capillary blood glucose level is monitored and he is given insulin. The nurse explains that which is the reason for monitoring glucose levels and administering insulin?
TPN contains concentrated carbohydrates and raises blood glucose.
The nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Which instructions should the nurse place on the list? Select all that apply.
Tea and coffee are restricted on the day of the test. 3.The test will take between 45 minutes and 2 hours. 4.The hair should be washed the evening before the test.
The nurse is assigned to care for a client who has just returned to the nursing unit following a renal biopsy. The nurse plans to do which actions to properly care for this client for the remainder of the shift? Select all that apply.
Test the urine for occult blood. Observing the urine and biopsy site for bleeding.
A client who has undergone a barium enema is being readied for discharge from the ambulatory care unit. Which instruction should the nurse include in instructions to the client?
The barium will cause the stools to be clay colored, but then the stool becomes normal colored.
The nurse is completing the laboratory requisition that will accompany an arterial blood gas (ABG) specimen sent to the laboratory for analysis. The nurse understands that which data will be needed by the laboratory for adequate evaluation of the specimen? Select all that apply.
The client's temperature 3. The date the specimen was drawn 4. The time the specimen was drawn 5. Any supplemental oxygen the client is receiving
A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. The nurse should tell the client which information about the test?
The dye injected may cause a warm, flushing sensation.
The nurse is reinforcing instructions to a client who is to have a gallium scan about the procedure. The nurse should include which item as part of the instructions?
The gallium will be injected intravenously 2 to 3 hours before the procedure.
The nurse is observing a nursing student preparing to obtain a throat culture on a client suspected of having a beta-hemolytic Streptococcus infection. Which actions indicate the need for further teaching regarding collecting this specimen? Select all that apply.
The student asks the client to tilt the head forward and to open the mouth. The student places the collection swab initially at the back of the client's tongue.
An ultrasound of the gallbladder is scheduled for the client with a suspected diagnosis of cholecystitis. Which should the nurse explain to the client about this test?
The test requires the client to lie still for short intervals.
The nurse is explaining to a client the reason a peak and trough has been prescribed because the client is receiving an antibiotic. Which reason for the blood levels should be included in the teaching plan?
To determine if the dose of the antibiotic is effective against the organism causing the infection
The nurse is reviewing the laboratory studies of a client receiving epoetin alfa. When should the nurse expect to note a therapeutic effect of this medication on the hemoglobin and hematocrit?
Two months after therapy
A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. The nurse assists with performing Allen's test before drawing the blood to determine the adequacy of which?
Ulnar circulation
The nurse is assisting in the care of a client for whom an arterial blood gas (ABG) must be drawn. The nurse notes that the person who draws the blood sample from the radial artery performs an Allen's test first. The nurse recognizes that this is being done to determine the adequacy of which circulations? Select all that apply.
Ulnar circulation 2.Radial circulation 3.Carotid circulation
A client with ascites is scheduled for a paracentesis. The nurse is assisting the primary health care provider (PHCP) with performing the procedure. Which position should the nurse assist the client into for this procedure?
Upright
The nurse is caring for a client with a diagnosis of gout. Which laboratory value should the nurse expect to note in the client?
Uric acid level of 8.4 mg/dL
A client has been diagnosed with pernicious anemia. In planning care for the client, the nurse anticipates that the client will be treated with which vitamin or mineral?
Vitamin B12
The nurse is reviewing laboratory results and notes that the client's international normalized ratio (INR) is 2.2. The nurse should realize this test is performed to monitor the effectiveness of which medication?
Warfarin
A client with leukemia who had a bone marrow aspiration is thrombocytopenic. The nurse gives which instruction to the family as the client is discharged to home?
Watch the puncture site for bleeding for the next several days.
A client is admitted to the hospital with a fever and extreme weakness. Which laboratory studies are likely to be elevated if the client is experiencing an infection? Select all that apply.
White blood cell count (WBC) 5.Erythrocyte sedimentation rate (ESR)
The nurse has given dietary instructions to a client to minimize the risk of osteoporosis. The nurse determines that the client understands the recommended changes if the client verbalizes the intention to increase intake of which foods? Select all that apply.
Yogurt cottage cheese
The nurse is reinforcing instructions to a female client regarding the procedure for collecting a midstream urine sample. Which statement by the client indicates an understanding of the procedure?
"I need to collect the urine in the cup after I start to urinate."
A client who has undergone barium enema is being readied for discharge. The nurse determines that the client has understood discharge instructions when the client makes which statement?
"I will be sure the barium passes and watch for my stools to return to normal."
A 24-hour urine specimen for creatinine and electrolytes has been prescribed for a hospitalized client to evaluate kidney function. The nurse explains the procedure to the client. The client voids at 0900, and the urine is discarded. The client voids at 1200 and the urine is measured and placed in the collection container. At which time the next day should the 24-hour urine collection be complete? Fill in the blank with the correct military time.
0900
The nurse is assisting in performing an arterial blood gas (ABG) analysis on a client. The nurse initially implements which intervention after the blood gas is drawn to minimize the risk for uncontrolled bleeding?
Applying direct pressure to the site
A client who takes theophylline for chronic obstructive pulmonary disease (COPD) is seen in the urgent care center for respiratory distress. Just before initiating treatment for the respiratory distress, a sample for a theophylline level is drawn. The nurse notes the therapeutic range for the serum theophylline level is 10 to 20 mcg/mL and determines that the client may not be taking the medication as prescribed if which result is obtained?
6 mcg/mL
A client with hypertension has been prescribed a low-sodium diet. The nurse reinforcing instructions about foods that are allowed should include which foods in a list provided to the client? Select all that apply.
Fresh tomato Summer squash
A client is admitted to the hospital with a diagnosis of malnutrition. The nurse is told that blood will be drawn to determine whether the client has a protein deficiency. Which laboratory data indicate that the client is experiencing a protein deficiency? Select all that apply.
Albumin 2.2 g/dL Transferrin, 90 mg/dL 5.Prealbumin 10 mg/dL
The nurse is providing directions to a client about how to test a stool for occult blood. The nurse cautions that which could cause a false-negative result?
Ascorbic acid
The nurse has just confirmed that a client has been scheduled for a mammogram for the following week. The nurse reinforces that the client should take which actions? Select all that apply.
Avoid applying skin lotion on the day of the test. 3.Remove any necklaces before presenting for the procedure.
A client will undergo a barium swallow to confirm a diagnosis of a hiatal hernia. In preparation for the test, which instruction should the nurse provide the client?
Avoid eating or drinking after midnight before the test.
A nurse about to give a daily dose of digoxin and notes that a serum digoxin level drawn earlier in the day measured 2.7 ng/mL. The nurse should take which actions? Select all that apply.
Report the finding to the registered nurse. Gather data from the client related to signs of toxicity.
A client has just undergone endoscopy. Which is the essential postprocedure nursing intervention?
Check the gag reflex before giving oral foods or fluids.
A licensed practical nurse (LPN) is providing follow-up teaching after a client underwent an upper gastrointestinal (GI) series with diatrizoate used for contrast. The nurse instructs the client that which may occur from the diatrizoate?
Diarrhea
A client scheduled for a pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. The nurse gives a response to the client that provides reassurance, based on which understanding?
Discomfort may occur with needle insertion, and there is minimal exposure to radiation.
The nurse instructs a client at risk for hypokalemia from thiazide diuretic therapy about foods that are high in potassium. The nurse determines that there is a need for further teaching if the client states that which foods are high in potassium and should be included in the diet plan? Select all that apply.
Eggs White bread with butter
The nurse working the 3:00 to 11:00 pm shift notes that a client with coronary artery disease (CAD) has a prescription for serum lipid levels to be drawn in the morning. The nurse places the client on which dietary preparation to ensure accurate test results?
Fasting for 12 hours
A client is scheduled for an oral cholecystography. The nurse should plan to obtain what type of diet for the evening meal before the test?
Fat-free
The nurse has reinforced postprocedure instructions to a client who has undergone a colonoscopy. The nurse determines that there is a need for further teaching if the client makes which statement?
It is all right to drive an hour after the test is finished.
The nurse assists the primary health care provider in performing a lumbar puncture on a 3-year-old child with leukemia suspected of central nervous system (CNS) disease. In which position should the nurse place the child during this procedure?
Lateral recumbent with the knees flexed to the abdomen and head bent with the chin resting on the chest
A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin (aPTT) time is 65 seconds. The licensed practical nurse reviews the laboratory results with the registered nurse, anticipating that which action is needed?
Leaving the rate of the heparin infusion as is
A hospitalized client with heart disease who is taking digoxin has a digoxin level prescribed. The level is elevated above normal. Based on this finding the nurse plans to notify the registered nurse and primary health care provider (PHCP) and anticipates which additional interventions will be prescribed? Select all that apply.
Monitor the potassium level. 2.Place the client on cardiac monitor. Monitor the blood urea nitrogen (BUN) and creatinine.
A client has just undergone a gastroscopy. Which action should be taken by the nurse as the essential postprocedure nursing intervention?
Monitoring for the gag reflex
The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child. The results indicate an area of induration measuring 8 mm. Which correct interpretation should the nurse make about these results?
Negative
Which action should the nurse include in the plan of care for a client following a renal scan?
No special precautions are needed except to wear gloves if coming into contact with the client's urine.
A client with Crohn's disease is seen by the primary health care provider, and a complete blood count (CBC) has been prescribed. The nurse reinforces instructions to the client who will be reporting to the laboratory in the morning to have the blood test drawn. The nurse gives the client which information about this test?
No special preparation is necessary.
A pulmonary angiography is scheduled for a client suspected of having a pulmonary embolism. The nurse understands that which actions are an appropriate preprocedure care intervention? Select all that apply.
Obtain a signed informed consent form. 2.Prepare the anticipated entry site for local anesthesia. 3.Inquire whether the client has any allergies to shellfish. Ask whether client has ever experienced an allergy to any contrast media.
Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply.
Platelets 35,000 mm3 (35 × 109/L) 2.Sodium 150 mEq/L (150 mmol/L) Segmented neutrophils 40% (0.40) White blood cells, 3000 mm3 (3.0 × 109/L)
The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of U waves. The nurse checks the client and then reviews the results of the client's recent electrolyte results. The nurse expects to note which electrolyte value?
Potassium 3.0 mEq/L
A client is recovering from abdominal surgery and has a large abdominal wound. The nurse encourages the client to eat foods from which nutrient categories to promote wound healing? Select all that apply.
Protein Vitamin C
A client has a prescription to have radial arterial blood gases (ABGs) drawn. Before drawing the sample, an Allen's test will be performed. In performing the Allen's test, which blood vessel(s) should the nurse occlude?
Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the process with the other artery
The nurse is reading a computer printout of the results of a cerebrospinal fluid (CSF) analysis performed on an adult client who underwent lumbar puncture. The nurse knows that a reported value of 0 is normal for which substance in CSF?
Red blood cells
A clinic nurse has given a client the materials needed to test the stool for occult blood as part of a routine screening for colorectal cancer. When the client asks the nurse whether there are any special precautions that must be followed in doing this test, the nurse tells the client to avoid eating which food for at least a day before performing the test?
Red meat
The nurse is preparing a client for a magnetic resonance imaging (MRI) examination. Which action by the nurse is important?
Remove metallic objects from the client.
A CD4+ count has been prescribed for a child with human immunodeficiency virus (HIV) infection. The mother asks the nurse about the purpose of the test and why the test needs to be done if it is already known that the child has HIV. The nurse should reinforce which information to the mother? Select all that apply.
The CD4+ count is used to determine the child's immune status. The CD4+ count is used to identify the risk for disease progression. 4. The CD4+ count identifies the need for Pneumocystis jiroveci pneumonia prophylaxis after 1 year of age. 5. The CD4+ count is measured at ages 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. 6. More frequent monitoring of CD4+ counts is indicated when pneumonia prophylaxis and antiretroviral therapy are administered.
The nurse is developing a nutritional plan for an assigned client. Which is the most critical piece of data to collect before formulating the plan?
The presence of food allergies
A bone marrow aspiration is scheduled for a client suspected of having leukemia. What intervention does the nurse anticipate will be done to protect the aspiration site and client from becoming infected?
The site will be cleansed thoroughly with an antiseptic and allowed to air dry before the procedure.
The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates and is unable to obtain any residual tube feeding. Which action should the nurse take next?
Turn the client to the side and attempt to aspirate again.
A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to assist the registered nurse with which action?
Drawing a sample for prothrombin time (PT) and international normalized ratio (INR)
A newly pregnant client is asking how to prevent neural-tube birth defects. The nurse reinforces which food choices to include in the diet? Select all that apply.
Oranges 4.Broccoli Grapefruit
The nurse is caring for the client who is going to have an arthrogram using a contrast medium. Which data collected by the nurse should be of highest priority?
Allergy to iodine or shellfish
The nurse is assisting in preparing a client for a cardiac catheterization. The nurse understands that it is important to check the client's record for which history?
Allergy to shellfish
The nurse is reinforcing instructions to a client regarding how to decrease the intake of phosphorus in the diet. The nurse should tell the client that which food items are allowed with few restrictions in a phosphorus-restricted diet? Select all that apply.
Apples White bread 5.Egg whites
The nurse reviews a client's serum sodium level and notes that the level is 150 mEq/L (150 mmol/L). The primary health care provider prescribes dietary instructions for the client based on the sodium level. Which food items should the nurse instruct the client to avoid? Select all that apply.
Bacon 2.Salami Processed oat cereals
A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet?
Baked turkey
Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory results warrant a call to the primary health care provider (PHCP)? Select all that apply.
Calcium, 7 mg/dL 2.Magnesium, 1 mg/dL White blood cells (WBC), 3000 mm3
The nurse is asked to assist with preparing a client who will be receiving a continuous total parenteral nutrition (TPN) solution via a central line. The nurse plans to institute which interventions for this client related to the TPN? Select all that apply.
Central line dressing changes per protocol 2.Blood glucose monitoring around the clock Using an electronic infusion pump with the infusion Reviewing prescribed blood laboratory values including electrolytes
A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item?
Cheese
The nurse is reinforcing instructions to a client about complete/high quality protein foods. Which food choices would indicate the client understood the teaching? Select all that apply.
Chicken eggs
A client has a diagnosis of hyperphosphatemia. The nurse reinforces instructions by telling the client to eliminate which items from the diet? Select all that apply.
Chicken fish
A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing?
Chicken breast, broccoli, strawberries, and milk
An abdominal postoperative client has been tolerating a full liquid diet, and the nurse plans to advance the diet to solid food as prescribed. The nurse collects data regarding which important item before advancing the diet to solids?
Dentition and ability to chew
The nurse is caring for a client scheduled for magnetic resonance imaging (MRI). Which instruction does the nurse reinforce to the client?
Earplugs can be worn if the noise from the machine is uncomfortable.
A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client?
Fat-free beef broth
A client is having problems with blood clotting. Which food item should the nurse encourage the client to eat?
Green, leafy vegetables
The nurse is reviewing the complete blood count (CBC) laboratory results of a female adult client suspected of having iron deficiency anemia. The nurse reviews the results and determines that which results are consistent with this diagnosis? Select all that apply.
Hemoglobin (Hgb) 8.8 g/dL 2.Hematocrit (Hct) 30% Decreased mean corpuscular volume (MCV) 66 fL
The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse should tell the client to select which food item that is high in riboflavin?
Milk
The nurse caring for a male client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's laboratory results and notes a hematocrit level of 30%. Which action should the nurse take?
Report the abnormally low level.
The nurse prepares a client for the lumbar puncture procedure by which interventions? Select all that apply.
Review the coagulation laboratory studies. 2.Observe the lower lumbar area for skin infections. Check to see the client has a signed consent for the procedure.
The client is having a lumbar puncture (LP) performed. The nurse should place the client in which position for the procedure?
Side-lying, with legs pulled up and chin to the chest
A client with diabetes mellitus calls the clinic nurse to report that the blood glucose level is 150 mg/dL. After obtaining further data from the client, the nurse determines that the client ate lunch approximately 2 hours ago. How should the nurse interpret the data?
The blood glucose level is slightly higher than the normal value.
A client is receiving total parenteral nutrition and has been NPO. The primary health care provider (PHCP) prescribed small amounts of clear liquids today. The nurse's priority is to collect data regarding which criterion before giving the client anything by mouth?
The presence of the swallow reflex
A client has a prescription to receive purified protein derivative (PPD) 0.1 mL intradermally (tuberculin skin test). The nurse prepares to administer the PPD and obtains a tuberculin syringe with a 26-gauge, ⅝-inch needle. Which technique should the nurse use to insert the needle?
Almost parallel to the skin with bevel side up
The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do? Select all that apply.
Document the amount of residual. Reinstill the residual and administer the feeding.
A hospitalized client is a lacto-vegetarian. Which food item should the nurse remove from the meal tray?
Eggs
The nurse is reinforcing teaching to a client about an upcoming colonoscopy procedure. The nurse should include in the instructions that the client will be placed in which position for the procedure?
Left Sims' position
When reinforcing dietary instructions to a client with irritable bowel syndrome whose primary symptom is alternating constipation and diarrhea, the nurse should tell the client that which foods are best to include in the diet for this disorder? Select all that apply.
apples whole grain bread
The client has just undergone computed tomography (CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of postprocedure care?
"I should drink extra fluids for the remainder of the day."
The nurse has provided instructions to a client scheduled for a mammography regarding the procedure. Which statement by the client indicates an understanding of the procedure?
"I should not wear deodorant on the day of the test."
The nurse informs a client that a Papanicolaou smear will be done at the next scheduled clinic visit, and the nurse provides instructions to the client regarding preparation for this test. Which statement by the client indicates an understanding of the procedure?
"If I have my period at the time of my next scheduled visit, I will not be able to have the test done."
A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week, yet is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern about not being able to continue the tube feedings at home with family caregivers. Which nursing response would be appropriate at this time?
"Tell me more about your concerns with your feedings after going home."
The nurse volunteering at the health screening clinic reinforces instructions to a 22-year-old client that diet and exercise should be used as tools to keep the total cholesterol level under at least which level?
200 mg/dL
The nurse is preparing to administer a continuous tube feeding to a client with a nasogastric tube. The primary health care provider has prescribed an amount of 100 mL/hr. The tube feeding setup is an open system, a bag that has formula added at intervals. How much formula should the nurse plan to add to fill the feeding bag?
400 mL of formula
The nurse reinforces what information to a client who is scheduled for an electromyogram (EMG)?
Electrodes will be inserted into the skeletal muscles.
The nurse is assigned to assist in caring for a client who is receiving parenteral nutrition with fat emulsion. The nurse is instructed to monitor the client for signs of fat overload. The nurse monitors for which signs and symptoms of this complication?
Fever and pruritic urticaria
The nurse is providing dietary instructions to a client with a diagnosis of ulcerative colitis. The client is prescribed to follow a low residue diet during episodes of diarrhea. Which food should the nurse instruct the client to avoid?
Fresh corn on the cob
The nurse is reviewing the laboratory results of a client scheduled for surgery. Which laboratory result should indicate to the nurse that the surgery might be postponed?
Hemoglobin, 8.4 g/dL
The nurse is reinforcing instructions to a client on how to decrease the intake of potassium in the diet. The nurse determines the need for further teaching if the client selects which foods to include in the diet? Select all that apply.
Potatoes 5.Avocados 6.Salt substitute
A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to reinforce teaching the client about the need for which measure?
Preventing and recognizing hyperglycemia
The nurse is preparing to care for a client following a lumbar puncture. The nurse plans to place the client in which position immediately after the procedure?
Prone with a pillow under the abdomen
A client is suspected of having a myocardial infarction. The nurse should expect elevations in which laboratory values to support the diagnosis? Select all that apply.
Troponin I Creatinine phosphokinase MB (CPK-MB)
The nurse reinforces dietary instructions to a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines the client has understood if the client plans to include which foods in the diet? Select all that apply.
Raisins 3.Kiwifruit 4.Bananas
A client with diabetes mellitus has a glycosylated hemoglobin A (HbA1c) level of 8%. Which instruction does the nurse plan to reinforce to the client based on this test result?
Prevent hyperglycemia.
The nurse needs to increase the calcium in the diet of a client who is lactose intolerant. Which food items should the nurse encourage? Select all that apply.
Tofu Broccoli 5.Sardines 6.Mustard greens
A client is seen in the urgent care center for complaints of chest pain 2 days ago. Since that time, the client has not been feeling well and fatigues easily. The nurse reviews the results of the laboratory tests. An elevation of which laboratory test indicates a myocardial infarction occurred at the time of chest pain 2 days ago?
Troponin I
