BSN 225 - Sherpath (Week 4) Clinical Judgment
Observing the patient's gait and testing balance are included in which element of the adult head-to-toe examination with patient standing? Spinal Abdominal Neurologic Musculoskeletal
Neurologic Observing the patient's gait and testing balance are included in the neurologic element of the adult head-to-toe examination with the patient standing.
Which time of day is best to collect a sputum sample? 07:00 12:00 16:00 19:00
07:00 Sputum samples should be taken first thing in the morning because there has been an accumulation of secretions overnight; the best time is 07:00.
Which factor is indicated by the mean corpuscular volume? Size of erythrocyte Amount of hemoglobin in erythrocytes Proportion of red blood cells to total blood volume Proportion of an erythrocyte occupied by hemoglobin
Size of erythrocyte Mean corpuscular volume (MCV) is a measure of the average size of an individual erythrocyte. Rationale for Incorrect: The mean corpuscular hemoglobin (MCH) is the average amount of hemoglobin in one erythrocyte. Hematocrit (Hct) is the proportion, or percent, of a person's total blood volume that is made up of red blood cells. The mean corpuscular hemoglobin concentration (MCHC) is the proportion, or fraction, of an erythrocyte that is occupied by hemoglobin.
The assessment of financial resources and health insurance is included in which element of the functional examination? Social situation Review of systems Physical examination Activities of daily living
Social situation The assessment of financial resources and health insurance is included in the social situation element of the functional examination.
Which coagulation test measures the amount of a plasma protein present in the blood? Platelet count International normalized ratio Fibrinogen level Prothrombin time
Fibrinogen Fibrinogen is a plasma protein that assists in blood clotting. Rationale for Incorrect: Platelets are not plasma proteins; they are a cell type. The international normalized ratio is a measure of prothrombin time of a patient compared with a control sample; it does not measure plasma proteins. Prothrombin time is a test that assesses the amount of time blood clots; it does not measure plasma proteins.
Which element of the functional assessment should be included during the review of systems? Blood pressure Ability to bathe Neurologic function Signs of dementia
Signs of dementia Assessing for signs of dementia is an element that should be included in the review of systems
Which medical condition can be diagnosed by a fecal fat stool test? Malabsorption Colon cancer Gastrointestinal parasite infection Gastrointestinal tract bleeding
Malabsorption Steatorrhea, or the failure to digest and absorb dietary fat, is a malabsorption syndrome that can be detected through a fecal fat stool test.
Which phrase describes an advantage of fine-needle aspiration? Elimination of pain Administration of medication Rapid administration of fluid Minimization of trauma to organs
Minimization of trauma to organs Because the needle used is thin, it is less likely to damage surrounding organs and structures.
Which cardiac marker findings support a suspicion of cardiac muscle damage after an infarction? Select all that apply. Total creatine kinase level of 100 units/L Myoglobin level of 100 ng/mL Troponin I level of 0.07 ng/mL Creatine kinase-MB (CK-MB) of 5% Alkaline phosphatase level of 60 units/L Not Sure
Myoglobin level of 100 ng/mL The expected level of myoglobin is less than 90 ng/mL. Elevated levels of myoglobin indicate cardiac damage. Troponin I level of 0.07 ng/mL The expected level of troponin I is less than 0.03 ng/mL. Elevated levels of troponin I indicate cardiac damage. Creatine kinase-MB (CK-MB) of 5% Levels of CK-MB of greater than 3% indicate cardiac damage. Rationale for Incorrect: The expected levels of creatine kinase are 30-135 units/L in females and 55-170 units/L in males. Normal levels of creatine kinase do not indicate infarction damage; elevated levels indicate damage. The expected level of alkaline phosphatase is 30-120 units/L. The level of alkaline phosphatase is not a measure of cardiac muscle damage; elevated levels occur with liver damage.
Which information would the nurse use to identify a patient before collecting a sample for diagnostic testing? Select all that apply. Name Date of birth Room number Home address Social security number
Name National safety patient goals suggest using two patient identifiers when identifying a patient. One identifier is patient name. Date of birth National safety patient goals suggest using two patient identifiers when identifying a patient. One identifier is patient date of birth. Rationale for Incorrect: Room number is not an appropriate identifier because the patient room number can change. Patient home address is not an appropriate identifier because the patient location can change. Social security number is not an appropriate identifier; to protect identity (and possible identity theft), social security numbers are not usually used as identifiers in health care systems.
Palpation of the thyroid and cervical lymph nodes is included in examination of which part of the body? Eyes Neck Mouth Pharynx
Neck Palpation of the thyroid and cervical lymph nodes is included in examination of the neck.
Which element of the assessment should be performed with the patient seated and wearing a gown? Percussion of the posterior chest Inspection of facial symmetry Auscultation of heart and lungs Palpation of axillary lymph nodes
Inspection of facial symmetry Inspection of facial symmetry should be performed after the patient has been assisted onto the examination table in the seated position.
Which signs would the nurse recognize as indicative of an allergic reaction to a contrast medium? Select all that apply. Itching Urticaria Vomiting Abdominal pain Respiratory distress
Itching Itching is a sign of an allergic reaction. Urticaria Urticaria, which is a red, raised, itchy skin rash also known as hives, is a sign of an allergic reaction. Respiratory distress Respiratory distress is a sign of a severe allergic reaction to a contrast medium. Rationale for Incorrect: Signs of mild to severe allergic reactions to contrast media include mild flushing, itching, urticaria, respiratory distress, and hypotension. Vomiting and abdominal pain are not one of them.
Which blood chemistry findings are consistent with diabetes mellitus? Select all that apply. Level of low-density lipoproteins (LDLs) of 160 mg/dL Plasma glucose level of 150 mg/dL Triglycerides 210 mg/dL Level of high-density lipoproteins (HDLs) of 57 mg/dL Level of 10% glycosylated hemoglobin Total cholesterol of 150 mg/dL
Level of low-density lipoproteins (LDLs) of 160 mg/dL The normal value of LDLs is <130 mg/dL. A level of 160 mg/dL is high, and an elevated LDL level is associated with diabetes mellitus. Plasma glucose level of 150 mg/dL Normal plasma glucose level is between 74 and 106 mg/dL. A level of 150 mg/dL is high; elevated plasma glucose levels occur with diabetes mellitus. Triglycerides 210 mg/dL The normal value of triglycerides is 40-160 mg/dL in males and 35-135 mg/dL in females. A level of 210 mg/dL is high, and elevated triglyceride levels are associated with diabetes mellitus. Level of 10% glycosylated hemoglobin Hemoglobin A1c (HbA1c), or glycosylated hemoglobin testing, evaluates plasma glucose levels over a period of 2 to 3 months. The normal value of HbA1c in patients without diabetes is 4% to 5.9% of hemoglobin. In patients with controlled diabetes, the HbA1c value is below 7%. A level of 10% is consistent with uncontrolled diabetes mellitus. Rationale for Incorrect: The normal level of HDLs is >45 in males and >55 mg/dL in females. An HDL level of 57 mg/dL is normal for either sex, so it is not a sign of diabetes mellitus. The normal value of total cholesterol is <200 mg/dL. A total cholesterol level of 150 mg/dL is within the normal range. A normal total cholesterol level is not a sign of diabetes mellitus.
Which element of the assessment should be performed after assessment of the patient's back, posterior chest, and lungs? Weber test Palpation of apical pulse Palpation of posterior chest Inspection of spine and scapula
Palpation of apical pulse After assessment of the patient's back, posterior chest, and lungs has been performed, the nurse should move to the front of the patient to begin examining the left side of the chest, which includes palpating the apical pulse.
Which examination component should be performed while the adult patient is supine with the legs exposed? Palpation of breast tissue Palpation of popliteal pulse Palpation for inguinal hernia Palpation for aortic pulsation
Palpation of popliteal pulse Palpation of the popliteal pulse should be performed while the adult patient is supine with the legs exposed.
Match the postprocedural care with the relevant procedure. Procedure: Paracentesis Thoracentesis Lumbar puncture Bone marrow aspiration Postprocedural care: Measure intake and output Encourage fluids Maintain bedrest for at least an hour Check the puncture site for crepitus
Paracentesis --> Measure intake and output Thoracentesis --> Check the puncture site for crepitus Lumbar puncture --> Encourage fluids Bone marrow aspiration --> Maintain bed rest for at least an hour
Which patient information would be communicated to the laboratory when collecting a clean-catch urine sample to avoid a false-positive result for hematuria? Patient is diabetic. Patient is menstruating. Patient has an enlarged prostate. Patient is constipated.
Patient is menstruating. It is important that the nurse document that the patient is menstruating to avoid a false-positive result for hematuria; blood from menstruation can contaminate the sample.
Which components are included in the functional assessment? Select all that apply. Social assessment Injury assessment Physical examination Evaluation of activities of daily living Comprehensive history
Social assessment Physical examination Evaluation of activities of daily living Comprehensive history
Order the elements of the abdominal/genital assessment that should be performed while the male patient is standing. Instruct the patient to relax the buttocks Inspect the perianal area Ask the patient to lean over examination table Palpate rectal sphincter tone
1 Ask the patient to lean over examination table 2 Instruct the patient to relax the buttocks 3 Inspect the perianal area 4 Palpate rectal sphincter tone The order of examination according to the guidelines for assessing the abdominal/genital area is as follows: ask the patient to lean over the examination table, instruct the patient to relax the buttocks, inspect the perianal area, and palpate the sphincter tone.
Place the elements of a seated examination in the correct order. Auscultate anterior chest and palpate breasts Assess head, ears, eyes, nose, and throat Inspect back and percuss posterior chest Gather supplies and greet the patient
1 Gather supplies and greet the patient 2 Assess head, ears, eyes, nose, and throat 3 Inspect back and percuss posterior chest 4 Auscultate anterior chest and palpate breasts Before performing a seated examination, the nurse should first gather supplies and greet the patient. Next, the nurse should assess the head, ears, eyes, nose, and throat. The nurse should then inspect the back and percuss the posterior chest. Finally, the nurse should auscultate the anterior chest and palpate the breasts.
Order the elements of an abdominal examination of an adult who is supine. Auscultate all four quadrants Percuss all four quadrants for tone Deeply palpate all four quadrants Inspect the skin and contour Lightly palpate all four quadrant
1 Inspect the skin and contour 2 Auscultate all four quadrants 3 Percuss all four quadrants for tone 4 Lightly palpate all four quadrants 5 Deeply palpate all four quadrants When performing an abdominal examination of an adult who is supine, the nurse should begin with inspection of the skin and contour, and follow with auscultation, percussion, and light and deep palpation, respectively, of all four quadrants. This order of examination follows the guidelines for assessing the abdomen, which include inspection, auscultation, percussion, and light palpation followed by deep palpation.
A delayed reaction to contrast material used in a diagnostic study occurs how many hours after the patient receives it. Record your answer as a range of two whole numbers separated by a hyphen.
2-6 hours A delayed reaction to contrast material is a reaction that occurs 2 to 6 hours after administration.
Place the examination components in order for the adult patient who is supine. Percuss liver border Inspect abdomen Auscultate heart Palpate for pedal edema
Auscultate heart Inspect abdomen Percuss liver border Palpate for pedal edema To assess an adult patient who is in the supine position, the nurse should start at the head and work down, keeping in mind the fact that the abdomen should be inspected before being percussed. The correct order for a head-to-toe assessment while the patient is lying down is as follows: auscultate the heart, inspect the abdomen, percuss the liver border, and finally, palpate for pedal edema.
A patient with type 2 diabetes mellitus tells the nurse that he has been testing his own blood glucose level six times per day for the past 3 years. What is the most appropriate action for the nurse to take? A. Observe the patient's testing technique for accuracy. B. Advise the patient that he is not permitted to perform his own blood glucose testing. C. Check with the patient's health care provider concerning the patient's self-testing. D. Explain to the patient that a nurse must complete blood glucose testing.
A. Observe the patient's testing technique for accuracy. Rationale: It is useful to evaluate the patient's technique to ensure that he receives accurate results. This patient has been self-testing for several years, and there is no reason to advise him not to continue doing so. To the contrary, frequent self-testing promotes optimal blood glucose control, and the nurse should encourage him to continue. The patient has given the nurse no reason to consult the health care provider. The policy that a nurse must complete the blood glucose testing varies among medical facilities.
The healthcare provider palpates the prostate gland and seminal vesicles with the patient standing as part of which element of the examination? Spinal Rectal Neurologic Abdominal/Genital
Abdominal/Genital Palpating the prostate gland and seminal vesicles is included in the examination of the abdomen/genitalia with the patient standing.
When a patient must provide a specimen for diagnostic testing at home, which factor is most important for the nurse to assess in the patient? Ability to arrange for transport for a follow-up appointment with health care provider Previous experience with specimen collection Ability to follow the correct collection technique Communication with the health care provider about specimen collection at home
Ability to follow the correct collection technique The nurse should assess the patient's ability to follow correct collection techniques; this will help the nurse determine if the patient can perform this task appropriately.
Which blood test is used to monitor heparin therapy? Platelet count Prothrombin time (PT) International normalized ratio (INR) Activated partial thromboplastin time (aPTT)
Activated partial thromboplastin time (aPTT) The aPTT is used to titrate and monitor heparin therapy. It is a measure of the function of the intrinsic clotting system and the length of time for blood to clot. Rationale for Incorrect: Platelet count is used to determine the risk for bleeding and to aid in the diagnosis of certain blood disorders. The PT test is used to monitor and titrate warfarin therapy. The INR is used to make the results of PT testing comparable, regardless of which laboratory or method of testing is used.
Match the blood test to the disorder it can indicate. Disorder: Anemia Infection Impaired clotting Blood test: RBC WBC Platelet
Anemia --> Red blood cell count Infection --> White blood cell count Impaired clotting --> Platelet count
Which conditions are consistent with a plasma glucose level of 50 mg/dL? Select all that apply. Anxiety Diabetes Obesity Malabsorption Excessive exercise Overproduction of insulin
Anxiety Malabsorption Excessive exercise Overproduction of insulin The reference range for plasma glucose is 74 to 106 mg/dL.
Which element is included in the physical examination component of the functional assessment? Reviewing health insurance coverage Determining existence of advance directive sAssessing the skin for signs of decubitus ulcers Asking the patient about activities of daily living
Assessing the skin for signs of decubitus ulcers Assessing the skin for signs of decubitus ulcers is an element of the functional assessment physical examination.
For which situation would the procedure of glucose testing be interrupted? A. The reagent strip code matches the code on the vial. B. An unused lancet is not available. C. The glucose meter beeps. D. A drop of blood forms on the patient's skin after it is punctured.
B. An unused lancet is not available. Rationale: The unavailability of an unused lancet would preclude proceeding with blood glucose testing. A used lancet can never be reused, because of the risk for infection. The nurse must locate an unused lancet for the procedure. It is expected that the code on the test strip will match the code on the vial. Some glucose meters beep when the reading has been completed. The formation of a drop of blood is necessary for testing and is the expected result when the skin is punctured with a lancet.
Which action would the nurse carry out first when performing a blood glucose test on a patient with type 1 diabetes mellitus? A. Apply clean gloves to minimize the risk for contamination. B. Assess the patient's skin for possible puncture sites. C. Ask the patient to wash his or her hands and forearms with warm, soapy water. D. Determine the patient's preferred puncture site.
B. Assess the patient's skin for possible puncture sites. Rationale: The nurse's first action would be to assess possible puncture sites. Although appropriate, applying clean gloves, helping the patient with hygiene, and asking the patient which puncture site he or she prefers would not be the nurse's initial action.
Which essential information would the nurse include in the hand-off report when a patient is transferred to a recovery area after an invasive procedure? Select all that apply. Duration of the procedure Expected time of discharge Condition after the procedure Condition during the procedure Condition before the procedure All medications given during the procedure
Condition after the procedure The patient's condition after the diagnostic procedure is always included in a hand-off report when a patient is transferred to a recovery area. Condition during the procedure The patient's condition during the diagnostic procedure is always included in a hand-off report when a patient is transferred to a recovery area. Condition before the procedure The patient's condition before the diagnostic procedure is always included in a hand-off report when a patient is transferred to a recovery area. All medications given during the procedure A list of all medications the patient received during the procedure is always included in a hand-off report when a patient is transferred to a recovery area. Rationale for Incorrect: Duration of the procedure is not essential. Expected time of discharge is not essential.
When a patient reports for an invasive diagnostic procedure that involves the use of contrast material, which action would the nurse perform first? Check that a signed consent form is on file. Confirm the patient's identity. Ask about known allergies. Obtain baseline vital signs.
Confirm the patient's identity. The nurse confirms the patient's identity before initiating any element of care; therefore confirming the patient's identity is the nurse's initial action when a patient presents for a diagnostic procedure. Rationale for Incorrect: Before confirming the patient's identity, it would not be possible to check for a consent form completed by that patient. Asking about known allergies is critically important when contrast material is to be used; however, it is not the nurse's initial action on meeting the patient. Baseline vital signs would not be obtained before the patient's identity being confirmed.
The nurse has selected a finger as the puncture site to measure the blood glucose level of a female patient with type 2 diabetes mellitus and peripheral vascular disease (PVD). Although all of the actions listed below are appropriate, which one would be of particular benefit to this patient given her medical history? A. Reviewing her current medications B. Inspecting the selected finger for bruising C. Following standard precautions D. Keeping the finger in a dependent position during the puncture
D. Keeping the finger in a dependent position during the puncture Rationale: The nurse would keep the finger in a dependent position to encourage blood flow to the intended puncture site. Blood flow to the extremities is compromised in patients with PVD. Reviewing the patient's current medications is appropriate for all patients for whom blood glucose testing has been ordered, and doing so would have no specific benefit for a patient with the medical history described. Inspecting the intended puncture site for bruising is appropriate for all patients for whom blood glucose testing has been ordered, and doing so would have no specific benefit for a patient with the medical history described. Standard precautions are followed with all patients and would be of no specific benefit to a patient with the medical history described.
For which patient can the nurse delegate to nursing assistive personnel (NAP) the task of routine blood glucose monitoring? A. Patient with non-insulin-dependent diabetes for whom steroid therapy has been ordered B. Patient with type 2 diabetes who required insulin coverage at the last testing C. Patient with type 1 diabetes who has had nausea and vomiting for 24 hours D. Patient with type 2 diabetes who has had a closed reduction of a fracture of the right wrist
D. Patient with type 2 diabetes who has had a closed reduction of a fracture of the right wrist Rationale: The patient with the closed reduction of a fracture of the right wrist would affect his or her ability to self-perform blood glucose testing but would not affect his or her blood glucose level. The skill of blood glucose testing may therefore be delegated to NAP. The patient's steroid therapy medication makes the blood glucose unstable, therefore the skill of blood glucose testing may not be delegated to NAP. The patient's need for insulin coverage precludes the delegation of blood glucose testing to NAP. The patient's nausea and vomiting make the blood glucose unstable, therefore the skill of blood glucose testing may not be delegated to NAP.
Which elements should be performed after light palpation of all quadrants of the abdomen in the adult patient? Percussion of all quadrants Auscultation for bowel sounds Deep palpation of all quadrants Inspection of abdominal contour
Deep palpation of all quadrants Deep palpation is the element of the abdominal assessment that should be performed after light palpation of all quadrants; deep palpation should be done last because it is the maneuver most likely to cause discomfort or pain.
Before an invasive diagnostic procedure, which elements of patient care are the nurse's responsibility? Select all that apply. Documenting baseline vital signs Administering preprocedure medications Supervising the preparation for anesthesia Ensuring prescribed intravenous (IV) access Having the patient sign a consent form if one is not already in the chart
Documenting baseline vital signs The nurse documents the patient's vital signs so that they can serve as a baseline comparison for postprocedural measurements. Administering preprocedure medications The nurse will administer the preprocedural medications as directed by the medical care team. Ensuring prescribed intravenous (IV) access If necessary, the nurse will ensure that there is secure IV access to the patient. Rationale for Incorrect: The anesthesiologist is responsible for correctly planning and administering the anesthesia, not the nurse. The nurse checks that a consent form has been signed and witnessed but does not have the patient sign one. Having a patient sign a consent form is outside the nurse's scope of practice.
Place the steps of throat culture collection in the appropriate order. 12345 Place swab in tube and seal immediately. Visualize throat with a light while depressing the tongue. Label container and place in biohazard bag. Touch swab to inflamed or draining areas. Don gloves.
Don gloves. Visualize throat with a light while depressing the tongue. Touch swab to inflamed or draining areas. Place swab in tube and seal immediately. Label container and place in biohazard bag. This is not a complete list of steps involved in the collection of a throat culture. They are procedural elements which need to be done in a particular order if a valid, usable culture specimen is to be obtained.
On which elements should the nurse focus when performing the physical examination component of the functional assessment? Select all that apply. Determining caregiver's abilities Evaluating coordination and gait Assessing for dyspnea with exertion Asking about use of a cane or walker Measuring blood pressure while the patient is seated and standing
Evaluating coordination and gait Evaluating coordination and gait is an element the nurse should focus on in the physical examination. Assessing for dyspnea with exertion Assessing for dyspnea with exertion is an element the nurse should focus on in the physical examination. Measuring blood pressure while the patient is seated and standing Measuring blood pressure while the patient is seated and standing is an element the nurse should focus on in the physical examination.
Which event can result if a tourniquet remains in place for more than a minute during a venous blood draw? Hemolysis resulting in bruising. Inflammation resulting in tissue damage. Hemoconcentration resulting in erroneous blood values. Nerve compression resulting in muscle spasm distal to the site.
Hemoconcentration resulting in erroneous blood values. Stasis of the blood and hemoconcentration can occur when a tourniquet is left in place longer than a minute; inaccurate measures of blood components result. Rationale for Incorrect: Hemolysis occurs when a blood sample is shaken. Tissue damage can occur as a result of a tourniquet stopping blood flow. If tissue damage occurs, it is from oxygen deprivation, not inflammation. Nerve compression and muscle spasm do not occur as a result of a tourniquet being in place for longer than a minute.
Which steps performed before any specimen collection procedure are critical to patient safety? Select all that apply. Provide privacy. Identify the patient. Gather the equipment. Explain what is to be done to the patient. Notify the laboratory that the specimen will be arriving. Verify the health care provider's prescription for the specimen. Not Sure
Identify the patient. Identification of the patient using two identifiers is critical to patient safety. Verify the health care provider's prescription for the specimen. Verifying the prescription (i.e., what specimen is to be collected from which patient) is critical to patient safety. Rationale for Incorrect: Privacy is important, but it is not critical to patient safety. Gathering the needed equipment is essential, but it is not critical to patient safety. The patient should always be told what is going to be done and why, but these notifications are not critical to patient safety. Notifying the laboratory in advance of the arrival of a routine specimen is not necessary, and it is not critical to patient safety.
Which element of the examination is best performed while the adult patient is reclining at 45 degrees? Testing range of motion of feet, ankles, and knees Inspecting jugular venous distention and pulsation Performing bimanual palpation of uterus and cervix Observing the patient move from lying down to a seated position
Inspecting jugular venous distention and pulsation Inspecting jugular venous distention and pulsation is best performed while the adult patient is reclining at 45 degrees.
Place the following steps of the sputum collection procedure in the appropriate order. Provide oral care. Instruct patient to breathe deeply and cough. Label the container. Place sample in biohazard bag. Collect sample in a cup.
Instruct patient to breathe deeply and cough. Collect sample in cup. Label the container. Place sample in biohazard bag. Provide oral care. This is not a complete list of steps involved in the collection of a sputum sample. The answer choices are procedural elements that need to be done in a particular order if a valid, usable specimen is to be obtained. First, the nurse instructs the patient to take a few deep breaths and then cough. The sputum is collected in a sterile cup, which the nurse immediately labels using two patient identifiers. The nurse places the specimen in a biohazard bag for transport to the laboratory. The nurse provides oral care once the specimen is ready for transport to the laboratory.
Which coagulation test is commonly used to monitor the effectiveness of warfarin? Platelet count International normalized ratio (INR) Fibrinogen levels Activated partial thromboplastin time (aPTT)
International normalized ratio (INR) The INR is a method of standardizing reports of prothrombin time results. Use of the INR makes results of prothrombin time testing comparable regardless of which laboratory or method of testing is used. The INR is commonly used to guide warfarin therapy. Rationale for Incorrect: Platelet count cannot determine whether the patient is using an effective dose of warfarin. Platelet count may be used to assess other conditions. Fibrinogen levels cannot determine whether the patient is using an effective dose of warfarin. Fibrinogen levels can identify suspected bleeding disorders and liver disease. aPTT time is commonly used to guide heparin therapy but not warfarin therapy.
Which action would the nurse take first when told by a patient arriving for a diagnostic test that requires an 8-hour fast that a glass of ginger ale and a grilled cheese sandwich were eaten 6 hours earlier? Reschedule the examination. Document the information. Notify the health care provider. Ask the patient about gastrointestinal (GI) distress.
Notify the health care provider. The nurse would immediately notify the health care provider so that updated prescriptions can be obtained. Rationale for Incorrect: The examination is likely to be rescheduled, but this is not the nurse's decision and therefore not the nurse's first action. It is important that the nurse document the information, but notification of the health care provider takes precedence, so documentation is not the first action. The fact that the patient did not comply with the preprocedure fast does not indicate the need to ask about GI distress.
Which elements are included in the review of systems for the functional assessment? Select all that apply. Nutritional status Memory changes Urinary incontinence Prior falls or fear of falling Identification of caregivers
Nutritional status Assessment of nutritional status is an element of the review of systems for the functional assessment. Memory changes Assessment of memory changes is an element of the review of systems for the functional assessment. Urinary incontinence Assessment of urinary incontinence is an element of the review of systems for the functional assessment. Prior falls or fear of falling Assessment of prior falls or fear of falling is an element of the review of systems for the functional assessment.
Which element is performed after inspection and palpation of the patient's spine while the patient is standing? Test abdominal reflexes Palpate axillary lymph nodes Assess radial and brachial pulses Observe the patient walk heel to toe
Observe the patient walk heel to toe Observing the patient walk heel to toe is the next element that should be performed after inspection and palpation of the patient's spine.
Which action would the nurse take if a patient accidently urinates into the stool collection container? Use the sample as is. Obtain a new sample. Send the sample after draining urine. Notify the health care provider.
Obtain a new sample. If urine contaminates a stool sample, the nurse should discard the sample and obtain a new sample from the patient.
Which outcome is applicable to a hypothesis of Anxiety? Flushing, itching, and urticaria are absent. Patient respirations are easy with a rate within an expected range. Patient remains free of injury related to the diagnostic procedure. Patient's understanding of the diagnostic procedure is free of misconceptions.
Patient respirations are easy with a rate within an expected range. Anxiety can result in many physiologic effects. Shortness of breath and rapid breathing are two common respiratory effects. When Anxiety is relieved, respirations return to an expected range. Rationale for Incorrect: Flushing, itching, and urticaria are absent. This outcome is related to risk for allergic reaction. Patient remains free of injury related to the diagnostic procedure. An outcome in which the patient remains free of injury is related to Risk for Injury. Patient's understanding of the diagnostic procedure is free of misconceptions. An outcome in which the patient would understand the procedure would relate to the patient's knowledge of the procedure.
To whom is the nurse responsible for communicating test results? Office staff Nurse coworker Laboratory manager Prescribing health care provider
Prescribing health care provider The nurse has a responsibility to communicate the patient's test results with the prescribing health care provider.
Which coagulation test results are desirable for a patient on warfarin therapy? Select all that apply. Prothrombin time (PT) 1.5-2.0 greater than the control value Platelet count of 250,000 cells/mm3 An activated partial thromboplastin time (aPTT) 1.5-2.0 less than the control value Fibrinogen level greater than 400 mg/dL International normalized ratio (INR) between 2 and 3
Prothrombin time (PT) 1.5-2.0 greater than the control value The PT is a measure of how long it takes the blood to clot. It is a useful measure of the effectiveness of the anticoagulant warfarin. The target PT for a person on warfarin therapy is 1.5-2.0 times the control value of 11-12.5 seconds. International normalized ratio (INR) between 2 and 3 The INR is a method of standardizing reports of PT. The normal INR is 0.8-1.1 for a patient who is not on anticoagulant therapy and 2-3 for prophylaxis or treatment of venous thrombosis with warfarin. Rationale for Incorrect: Platelet count is not affected by warfarin therapy. The reference range for a platelet count is 150,000-400,000 cells/mm3. The aPTT is used to gauge or trend if heparin therapy is effective but is not used to evaluate warfarin therapy. The reference range for aPTT is 30-40 sec. The therapeutic level for anticoagulant therapy is 1.5-2.5 times greater than the control value. Fibrinogen levels do not change when a patient takes the anticoagulant warfarin sodium. Fibrinogen levels can identify suspected bleeding disorders and liver disease.
Which hypothesis is appropriate for a patient who has researched the planned procedure and requests time to clarify findings with the nurse? Anxiety Ready to Learn Lack of Knowledge of Diagnostic Test Nonadherence to Diagnostic Testing Regime
Ready to Learn When a patient researches the planned procedure and requests a discussion with the nurse, these are cues that the patient is Ready to Learn.
Which techniques can be used to obtain a sputum sample if coughing alone is ineffective? Select all that apply. Suctioning Use of expectorants Saline lavage Chest percussion Use of an aerosol or nebulizer Not Sure
Suctioning Suctioning using a catheter with a sputum trap is a technique that can be used to obtain a sputum sample. Use of expectorants Expectorants can be administered to facilitate obtaining a sputum sample. Expectorants help loosen secretions, making it easier to cough up sputum. Chest percussion Chest percussion helps loosen secretions, making it easier to bring up sputum by coughing. Use of an aerosol or nebulizer Use of aerosols or nebulizers for inhalation of a steamlike mist can facilitate coughing up a sputum sample. Rationale for Incorrect: Saline lavage is not an appropriate technique to use to obtain a sputum sample; nasal irrigation with saline may be used to relieve nasal congestion.
Which elements are included in the assessment of the hips of an adult patient? Select all that apply. Testing range of motion Palpating popliteal pulse Auscultating systematically Percussing for finger bone dullness Palpating for stability of joint
Testing range of motion Testing range of motion is an element included in the assessment of the hips of the adult patient. Palpating for stability of joint Palpating for joint stability is an element included in the assessment of the hips of the adult patient.
Which elements are included in the assessment of the mouth and pharynx? Palpating the thyroid Testing the gag reflex Inspecting the septum Assessing the carotid pulse
Testing the gag reflex Testing the gag reflex is an element included in the assessment of the mouth and pharynx.
Which assessment element of the adult head-to-toe examination is best performed with the patient standing? Palpating the abdomen Testing plantar reflexes Assessing jugular pulsation The Romberg test
The Romberg test
Which interpretation of activated partial thromboplastin time (aPTT) of 50 seconds is accurate? The patient has a significantly elevated value. The patient has a normal value. The patient has a significantly decreased value. The patient has a value indicative of a laboratory error.
The patient has a significantly elevated value. An aPTT value of 50 seconds is elevated. The normal range is 30-40 seconds. The aPTT value can be 1.5-2.5 times the control value with a normal range of 30-40 seconds. An aPTT of 50 seconds does not exceed this parameter, so there is no indication of laboratory error.
Which information would unlicensed assistive personnel (UAP) report to the nurse when performing blood glucose testing on a patient? Select all that apply. The patient showered and ambulated before the glucose test was done. The patient's blood glucose was 56 mg/dL. The required glucose tests have been completed. The patient is concerned about how many times a finger stick is performed. The patient is so swollen that blood cannot be obtained from the finger stick.
The patient's blood glucose was 56 mg/dL. The UAP should provide results to professional personnel in a timely manner. The required glucose tests have been completed. The UAP should notify the nurse when blood glucose testing has been completed. The patient is concerned about how many times a finger stick is performed. The UAP should notify the nurse of any concerns verbalized by the patient. The patient is so swollen that blood cannot be obtained from the finger stick. The UAP should notify the nurse of any difficulties in obtaining the blood used for glucose testing, such as being unable to obtain blood due to swelling.
For which reasons would a culture be prescribed? Select all that apply. To store samples To kill the microorganism To detect infection To identify the infecting organism To determine optimal treatment
To detect infection If the microorganism grows in the culture, the culture is considered positive, meaning infection is detected. To identify the infecting organism Once the microorganism has been successfully cultured, the culture will be used as the source of the microorganism in tests aimed at identification. Rationale for Incorrect: A sensitivity test, not a culture, is used to determine whether a microorganism is resistant to a certain antibiotic.
Match the patient with the related difficulty in obtaining a blood sample. Difficulty: Veins too small Veins fragile, risk for bleeding Veins difficult to visualize and/or access Patient: 25-year-old weighing 350 lbs 86-year-old weighing 120 lbs 3-month-old weighing 9 lbs
Veins too small --> 3-month-old weighing 9 pounds Veins fragile, risk for bleeding --> 86-year-old weighing 120 pounds Veins difficult to visualize and/or access --> 25-year-old weighing 350 pounds
Which question would the nurse ask a patient who collects a urine specimen at home? Select all that apply. "Was the specimen left unattended for any length of time?" "At which temperature was the specimen maintained?" "Who collected the specimen?" "How quickly was the specimen transported?" "Was the specimen transported by anyone other than the patient?"
"At which temperature was the specimen maintained?" For accurate urinalysis, if a urine sample does not go directly to the laboratory, it should be refrigerated. "How quickly was the specimen transported?" For accurate urinalysis, the urine sample must be fresh. If it is not directly transported to the laboratory, it should be refrigerated. Rationale for Incorrect: "Was the specimen left unattended for any length of time?" Whether or not the specimen was left unattended is not something that needs to be known. "Who collected the specimen?" The person who collected the specimen is not something that needs to be known. "Was the specimen transported by anyone other than the patient?" The person who transported the specimen is not something that needs to be known.
Which questions would the nurse typically ask a patient before sedation for a diagnostic procedure? Select all that apply. "Did you drink any alcohol within the last 24 hours?" "When was the last time you had anything to eat or drink?" "What was the date of your last visit to your primary health care provider?" "Can you tell me about the procedure you are having and ask any questions you may have about it?" "What prescription, over-the-counter, or herbal medications do you take on a daily basis?"
"Did you drink any alcohol within the last 24 hours?" The nurse should ask about consumption of alcohol in the last 24 hours because of the potential for interaction with medications used during the procedure and because of potential for impairment of the patient's ability to follow directions. "When was the last time you had anything to eat or drink?" The nurse would ask when the patient last ate or drank because recent oral intake may affect the safety with which the procedure can be performed. "Can you tell me about the procedure you are having and ask any questions you may have about it?" The nurse would ask about the patient's understanding of the procedure and provide additional information as appropriate because the patient has a right to know about the procedure and because the patient must give informed consent. "What prescription, over-the-counter, or herbal medications do you take on a daily basis?" The nurse would ask about all types of medications taken daily because of their potential impact on the patient's response to the procedure.
Which screening questions would the nurse ask a patient before magnetic resonance imaging (MRI)? Select all that apply. "When did you eat last?" "Do you get claustrophobic?" "Do you have any open wounds?" "Do you have a cardiac pacemaker?" "Are you wearing a watch or any jewelry?" "Do you have any metal objects in your body?" Not Sure
"Do you get claustrophobic?" An MRI scan is performed in an enclosed space, so patients may experience claustrophobia. "Do you have a cardiac pacemaker?" The magnet will attract metal-containing objects in the body, and the attraction can cause mechanical malfunction of internal devices, such as pacemakers. "Are you wearing a watch or any jewelry?" The magnet will attract all metal objects, including metal watches and jewelry; these should be removed prior to an MRI scan. "Do you have any metal objects in your body?" The MRI magnet will attract metal-containing objects in the body, and a patient should be screened for any objects, such as pacemakers, inner-ear implants, and other metal implants. Rationale for Incorrect: MRI technology is not affected by food or fluid ingestion. Patients with open wounds can safely undergo MRI because the magnetic fields do not negatively affect exposed body tissue.
Which questions would the nurse ask to evaluate the patient's ability to comply with the prescribed regimen of self-monitoring blood glucose? Select all that apply. "Have you monitored your glucose before?" "Has the diabetes educator seen you yet?" "Do you see yourself being able to check your blood glucose at the times prescribed?" "Are you able to buy your own glucometer, strips, and lancets?" "Do you have a friend or relative who self-monitors blood glucose?"
"Do you see yourself being able to check your blood glucose at the times prescribed?" Asking the patient about ability to comply with the prescribed regimen for self-monitoring blood glucose gives the patient an opportunity to express any reservations and to identify obstacles. "Are you able to buy your own glucometer, strips, and lancets?" Asking about the ability to buy needed equipment and supplies, such as glucometer, strips, and lancets, is a question designed to identify any financial constraints that would interfere with compliance with the monitoring regimen. Rationale for Incorrect: Asking if the patient has previously self-monitored glucose is not the way to evaluate ability to comply with the currently prescribed regimen for self-monitoring blood glucose. Even if the patient has previously monitored blood glucose in accordance with the prescribed regimen, life situations change. Compliance may not be possible now. Asking if the diabetes educator has seen the patient yet is not a way for the nurse to evaluate a patient's ability to comply with the prescribed regimen for self-monitoring glucose. Asking if the patient has a friend or relative who self-monitors blood glucose does not evaluate the patient's ability to comply with the currently prescribed regimen for self-monitoring blood glucose. Knowing someone who performs a skill does not reflect one's own ability to perform it.
Which questions might a nurse ask a patient during a preprocedural assessment to obtain essential information about the patient's medication history? Select all that apply. "Do you take any prescription medications on a regular basis?" "Have you taken any antibiotics within the past month?" "Are you allergic to any medications?" "Do you take any herbal medications?" "Have you taken any medication today?"
"Do you take any prescription medications on a regular basis?" It is essential to obtain information about prescription medications the patient may be taking because they may influence the patient's care. "Are you allergic to any medications?" It is essential to ask about allergies to medications so that the patient is not exposed to a known allergen. "Do you take any herbal medications?" It is essential to obtain information about herbal medications being taken because they may have implications for patient care. "Have you taken any medication today?" It is essential to obtain information about medication taken the day of the procedure because their effects must be considered when planning and carrying out the procedure and the postprocedural care.
Which direction would the nurse give to a patient who has had a thoracentesis? "Lie on the affected side for at least an hour." "Do not eat or drink until your gag reflex returns." "Notify the nurse if you experience trouble breathing." "Keep the arm on the affected side elevated for 4 hours."
"Notify the nurse if you experience trouble breathing." Observing for signs of respiratory distress is a critical nursing assessment for patients who have had a thoracentesis. Asking the patient to report trouble breathing helps ensure prompt identification and treatment of a problem. Rationale for Incorrect: The patient should lie on the unaffected side, not the affected side, for at least an hour to encourage full expansion of the lung. Thoracentesis does not affect the gag reflex. Elevating the arm on the affected side is not necessary after a thoracentesis.
Which instructions from the nurse to unlicensed assistive personnel (UAP) delegated to obtain a midstream clean-catch urine specimen are appropriate? Select all that apply. "Tell me when you have the sample." "Please collect the urine sample as soon as possible." "Be sure the area around the urethral meatus is thoroughly cleaned." "Use a sterile specimen cup and make sure not to touch the inside of the cup or the cover." "Please make sure the patient begins to urinate in the toilet, stops, and finishes urinating in the specimen cup."
"Tell me when you have the sample." The nurse is ultimately responsible for collection, labeling, and transport of the specimen, so asking for confirmation of the sample is appropriate. "Please collect the urine sample as soon as possible." The nurse should provide to UAP the time the urine needs to be collected. "Be sure the area around the urethral meatus is thoroughly cleaned." The nurse should instruct UAP on the areas to clean to prevent contamination of the specimen. "Use a sterile specimen cup and make sure not to touch the inside of the cup or the cover." The nurse should instruct UAP to prevent contamination of the specimen, such as using a sterile specimen cup and not touching the inside of the cup or cover. Rationale for Incorrect: "Please make sure the patient begins to urinate in the toilet, stops, and finishes urinating in the specimen cup." Instructing the patient to finish urinating in the specimen cup would be incorrect. The patient begins to urinate in the toilet, stops, urinates in the specimen cup, and then finishes urinating in the toilet.
Which information should unlicensed assistive personnel (UAP) collecting a stool sample provide the nurse immediately after collection? Select all that apply. "I put on gloves before I obtained the stool sample." "This stool sample is Hemoccult positive." "The patient said that it hurt to pass the stool." "The stool sample was clay colored." "The patient told me that he was not comfortable providing a stool sample with me there and asked for privacy."
"This stool sample is Hemoccult positive." Positive results of occult blood should be shared with the nurse immediately. "The patient said that it hurt to pass the stool." Concerns verbalized by the patient should be shared with the nurse immediately. "The stool sample was clay colored." Sample color, odor, and consistency should be shared with the nurse immediately. Rationale for Incorrect: The personal protective equipment, such as gloves, worn by UAP is not pertinent information to inform the nurse. It is not necessary for UAP to report that the patient asked for privacy. Difficulties encountered should be reported, but privacy is basically a standard request.
In which aspects of a procedure for collecting a sputum specimen should unlicensed assistive personnel (UAP) be educated? Select all that apply. Proper suctioning technique Appropriate handling of the specimen Appropriate collection of the specimen Appropriate processing of the specimen Reporting of procedural or physiologic difficulties
Appropriate handling of the specimen The UAP must be educated in appropriate handling of sputum before collecting the specimen. Appropriate collection of the specimen The UAP must be educated in the appropriate technique for collection of sputum before actual collection. Reporting of procedural or physiologic difficulties. The UAP must be educated about reporting any procedural or physiologic difficulties before collecting the specimen. Rationale for Incorrect: Suctioning is outside the scope of practice of UAP; therefore UAP do not need suctioning education. Processing sputum is not within the scope of practice of UAP. Processing is handled in the laboratory by a laboratory technician.
From which sources can blood be collected for diagnostic testing? Select all that apply. Arteries Veins Arterioles Venules Capillaries
Arteries Blood can be collected from arteries. The most common test on arterial blood is blood gas measurement. Veins Blood can be collected from veins. Most blood tests use venous blood. Capillaries Blood can be collected from capillaries; most frequently this is done with the use of lancets for blood sugar testing and for collecting blood samples in infants and young children with small veins. Rationale for Incorrect: Blood is not collected from arterioles; arterioles are too small for a needle and too deep for a lancet. Blood is not collected from venules; venules are too small for a needle and too deep for a lancet.
A patient arrives for an invasive diagnostic procedure and indicates that preprocedure NPO (nothing by mouth) instructions have not been followed. Which actions would the nurse take? Select all that apply. Ask what and how much the patient ate and drank. Reschedule the procedure. Notify the health care team. Document the information about the patient's eating and/or drinking. Ask when the patient ate and drank.
Ask what and how much the patient ate and drank. The nurse will ask what was ingested and approximately how much the patient ate and drank so that the health care team can determine whether the situation will affect the procedure. Notify the health care team. The nurse will notify the health care team so that the members can determine whether the procedure should be postponed. Document the information about the patient's eating and/or drinking. The nurse will document what, how much, and exactly when the patient ate and/or drank so that the health care team can determine whether the situation will affect the procedure. Ask when the patient ate and drank. The nurse will ask when the patient ate and drank so that the health care team can determine whether the situation will affect the procedure.
Which procedures require the patient to remain NPO (nothing by mouth) until the gag reflex returns? Select all that apply. Bronchoscopy Cystoscopy Colonoscopy Arthroscopy Esophagogastroduodenoscopy
Bronchoscopy A patient must remain NPO until gag reflex returns after a bronchoscopy due to risk for aspiration. Esophagogastroduodenoscopy A patient must remain NPO until gag reflex returns after an esophagogastroduodenoscopy due to risk for aspiration. Rationale for Incorrect: A patient does not need to remain NPO after a cystoscopy, colonoscopy, or arthroscopy because the gag reflex is not affected by this procedure.
Which element of the examination would the nurse perform while the adult patient is in a standing position? Auscultating lungs Inspecting the spine Testing stereognosis Palpating the carotid pulse
Inspecting the spine Inspecting the spine should be performed while the adult patient is in a standing position.
Which descriptors would the nurse use in reference to changes in a patient's condition after an allergic reaction to contrast media? Critical, stable, or good Satisfactory or unsatisfactory Urgent, concerning, or reassuring Improving, declining, or unchanged
Improving, declining, or unchanged Improving, declining, and unchanged are descriptors used in the evaluation of a patient's condition, and they indicate status relative to expected outcomes. These descriptors can convey not simply a current state but also the direction in which a patient's condition is moving. Rationale for Incorrect: Critical, stable, and good are adjectives open to individual interpretation, and they do not address expected outcomes in a meaningful fashion. Satisfactory and unsatisfactory are describing words open to individual interpretation, and they do not address expected outcomes in a meaningful fashion. Urgent, concerning, and reassuring are modifiers open to individual interpretation, and they do not address expected outcomes in a meaningful fashion.
The function of which organ is indicated by bilirubin level? Heart Kidneys Pancreas Liver
Liver Bilirubin levels are indicators of liver function. The normal value of bilirubin is 0.3-1.0 mg/dL.
Which procedure calls for neurologic assessment of the patient to evaluate for complications? Esophagogastroduodenoscopy Bronchoscopy Bone marrow aspiration Lumbar puncture
Lumbar puncture Lumbar puncture is a procedure in which a needle is inserted between two lumbar vertebrae into the spinal canal most often to obtain a sample of cerebrospinal fluid. Neurologic assessment is done after the procedure to check for complications related to entering the central nervous system.
Which information must the nurse routinely verify as part of assessment before any diagnostic test? Select all that apply. Patient's history of allergies Patient's ethnic affiliation Patient's insurance coverage Patient's understanding of what is to be done Patient's completion of any required preparation
Patient's history of allergies The nurse verifies the patient's history of allergies to protect the patient from exposure to a known allergen and/or to guide monitoring for signs of a reaction. Patient's understanding of what is to be done The nurse verifies that the patient knows what procedure is going to be done. This is a patient's legal right. Patient's completion of any required preparation The nurse verifies in detail that the patient has carried out the preparation for the procedure as directed. This is essential for the safety of the patient and for the success of the procedure.
Which measures would the nurse take to avoid stimulating the patient's gag reflex when obtaining a throat culture? Select all that apply. Place swab off center. Swab the patient's throat quickly. Have patient gargle with viscous lidocaine. Ask the patient to sit upright and say, "Ahh." Ask the patient to tilt the head to the side and say, "Ahh."
Place swab off center. The nurse should place swab off center to avoid triggering the gag reflex. Swab the patient's throat quickly. The nurse should swab quickly to avoid triggering the gag reflex. Ask the patient to sit upright and say, "Ahh." The nurse should have the patient sit upright and say, "Ahh," to avoid triggering the gag reflex. Rationale for Incorrect: Viscous lidocaine may be used in some procedures, but it is not used for a throat culture procedure. To minimize the patient's gag reflex, the patient should not tilt the head to the side. The nurse is not able to accurately avoid the gag reflex or swab quickly when patient tilts the head.
Which blood test results are consistent with obesity? Select all that apply. Plasma glucose level of 130 mg/dL Total cholesterol 180 mg/dL High-density lipoprotein (HDL) cholesterol 30 mg/dL Low-density lipoprotein (LDL) cholesterol 110 mg/dL Triglycerides 40 mg/dL
Plasma glucose level of 130 mg/dL Normal plasma glucose level is between 74 and 106 mg/dL. A level of 130 mg/dL is elevated. Obesity is associated with elevated glucose levels. High-density lipoprotein (HDL) cholesterol 30 mg/dL The normal value of HDLs is >45 mg/dL in males and >55 mg/dL in females. An HDL of 30 mg/dL is low, and a low level is consistent with obesity. Rationale for Incorrect: The normal value of total cholesterol is <200 mg/dL. A total cholesterol level of 180 mg/dL is within the normal range. An elevated cholesterol level is associated with obesity. Low-density lipoprotein (LDL) cholesterol 110 mg/dL The normal value of LDLs is <130 mg/dL. An LDL level of 110 mg/dL is within the normal reference range and is not associated with obesity. The normal value of triglycerides in males is 40-160 mg/dL, and in females, it is 35-135 mg/dL. Triglyceride level is not related to obesity.
Before which diagnostic test would the nurse ask a question about breastfeeding? Magnetic resonance imaging (MRI) Computed tomography (CT) scan Positron emission tomography (PET) scan Ultrasound
Positron emission tomography (PET) scan A PET scan uses a radioactive tracer, which can be excreted in breast milk, so breastfeeding needs to be stopped for 48 hours to give the tracer time to clear the body. Rationle for Incorrect: An MRI scan does not affect breastfeeding, so a question about breastfeeding is unnecessary. A CT scan does not affect breastfeeding, so a question about breastfeeding is unnecessary. An ultrasound does not affect breastfeeding, so a question about breastfeeding is unnecessary.
Which blood test results are consistent with anemia? Select all that apply. Hematocrit level of 60% Red blood cell (RBC) count of 3 cells/mm3 Hemoglobin level of 9 g/dL Neutrophil count of 9000 cells/mm3 Basophil count of 35 cells/mm3
Red blood cell (RBC) count of 3 cells/mm3 An RBC count of 3 cells/mm3 is low for newborns, children, and adult males and females. A low RBC count is a sign of anemia. Hemoglobin level of 9 g/dL A hemoglobin level of 9 g/dL is low for both adult males and females. A low hemoglobin level is a sign of anemia. Rationale for Incorrect: A hematocrit level of 60% is high for both adult males and females. Anemia is not associated with a high hematocrit level. An elevated hematocrit level may indicate cardiovascular disease, chronic lung disease, or polycythemia vera. Neutrophils & basophils are white blood cells. Anemia is not a white blood cell problem.
Which hypothesis is the immediate priority for a patient who is sedated before undergoing an invasive diagnostic procedure? Anxiety Ready to Learn Risk for Injury Lack of Knowledge of Diagnostic Test
Risk for Injury Sedatives can decrease alertness and coordination, increasing the patient's risk for having an injury.
Which hypothesis is being addressed when the nurse verifies with a patient that required preparation for a diagnostic test was done? Anxiety Risk for Injury Risk for Anaphylaxis Lack of Knowledge of Diagnostic Test
Risk for Injury The patient is at Risk for Injury when a test is done without proper preparation. An example is the risk for aspiration injury if the patient has not fasted before the test as instructed. Rationale for Incorrect: Anxiety Checking with the patient that directions for test preparations were followed does not alleviate Anxiety. Correcting misconceptions and providing information about safety and quality care can help mitigate Anxiety. Risk for Anaphylaxis Checking with the patient that directions for test preparations were followed does not affect the Risk for Anaphylaxis. Lack of Knowledge of Diagnostic Test Checking with the patient that directions for test preparations were followed does not provide knowledge about the diagnostic test.
A patient is having a magnetic resonance imaging (MRI) scan of the pancreas with contrast. Which hypothesis is the priority for this patient? Drug Dependence Risk for allergic reaction Lack of Family Support Lack of Trust in Health Care Provider
Risk for allergic reaction Risk for allergic reaction to the contrast medium is an immediate life-threatening problem; it is the highest priority.
Which responsibilities related to the collection of routine specimens for diagnostic testing are generally considered to be part of the nursing role? Select all that apply. Prescribing Scheduling Collecting Handling Documenting
Scheduling Collecting Handling Documenting
Which laboratory value is used to detect chronic kidney disease? Creatine kinase level Alanine aminotransferase level Albumin level Serum creatinine level
Serum creatinine level Elevated serum creatinine levels occur with chronic kidney disease.
A patient scheduled for a cystoscopy has no knowledge of the self-preparation for the procedure. Which patient-centered outcome is appropriate for the patient's hypothesis of Lack of Knowledge of Diagnostic Test? Using the patient instruction sheet as a guide, the patient will explain how to carry out self-preparation for the cystoscopy procedure. The patient will ask questions about self-preparation for a cystoscopy after the nurse's explanation of what is to be done. The patient will be attentive while a member of the health care team explains the purpose of the procedure. The patient will explain the importance of following the self-preparation protocol carefully.
Using the patient instruction sheet as a guide, the patient will explain how to carry out self-preparation for the cystoscopy procedure. Having the patient explain self-preparation for the cystoscopy is the most appropriate goal for this patient because it is the best measure of the patient's correct understanding of what needs to be done. Rationale for Incorrect: The patient will ask questions about self-preparation for a cystoscopy after the nurse's explanation of what is to be done. The patient's asking questions following the nurse's explanation of self-preparation may be a good thing, but it does not guarantee that the patient understands the whole procedure. The patient will be attentive while a member of the health care team explains the purpose of the procedure. The patient's attentiveness to the explanation of the procedure and its purpose does not address the knowledge deficit related to self-preparation for the procedure. The patient will explain the importance of following the self-preparation protocol carefully. The patient's ability to explain the importance of following the self-preparation protocol carefully is important, but it does not indicate that the patient knows how to implement it.
