Week 4 Questions for promotion

A delayed reaction to the 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. hours

2-6 hours A delayed reaction to contrast material is a reaction that occurs 2 to 6 hours after administration.

In which aspects of a procedure for collecting a sputum specimen should unlicensed assistive personnel (UAP) be educated? Select all that apply. A. Proper suctioning technique B. Appropriate handling of the specimen C. Appropriate collection of the specimen D. Appropriate processing of the specimen E. 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.

From which sources can blood be collected for diagnostic testing? Select all that apply. A. Arteries B. Veins C. Arterioles D. Venules E. 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.

Define Thoracentesis

Check the puncture site for crepitus

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. A. Duration of the procedure B. Expected time of discharge C. Condition after the procedure D. Condition during the procedure E. Condition before the procedure F. 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.

When a patient reports for an invasive diagnostic procedure that involves the use of contrast material, which action would the nurse perform first? A. Check that a signed consent form is on file. B. Confirm the patient's identity. C. Ask about known allergies. D. 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.

Which nerve does the nurse examine by evaluating eye movements and pupillary reflexes? A. Motor nerve B. Cranial nerve C. Sensory nerve D. Accessory nerve

Cranial nerve Cranial nerve assessment involves the eyes, upper nasal passages, pons, and medulla oblongata. Cranial nerves are assessed through evaluation of eye movements and pupillary reflex.

Which characteristic is the nurse assessing when placing thumbs on either side of the spine during the respiratory system assessment? A. Lung capacity B. Lung shape C. Respiratory rate D. Depth of respirations

Depth of respirations Depth of respirations is assessed by placing the thumbs on either side of the spine and noting thumb movement.

Before an invasive diagnostic procedure, which elements of patient care are the nurse's responsibility? Select all that apply. A. Documenting baseline vital signs B. Administering preprocedure medications C. Supervising the preparation for anesthesia D. Ensuring prescribed intravenous (IV) access E. 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.

Place the steps of throat culture collection in the appropriate order. Touch swab to inflamed or draining areas. Label container and place in biohazard bag. Visualize throat with a light while depressing the tongue. Place swab in tube and seal immediately. 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.

Define Lumbar Puncture

Encourage Fluids

Which priority action would the nurse take before beginning an examination of the breasts and genitals? A. Ensure proper positioning of the patient. B. Provide a quiet, calm environment. C. Ensure respect for the patient's privacy. D. Provide education regarding self-examinations.

Ensure respect for the patient's privacy. Respect for the patient's privacy and the patient's comfort level is the most important part of assessing the breasts and genitals.

Which region would the nurse palpate to assess for aortic vibrations? A. Epigastric area B. Midaxillary area C. Midthoracic area D. Periumbilical area

Epigastric area Palpating the epigastric area will allow for a proper assessment of aortic vibrations.

Match the type of neurologic examination to the appropriate description. Eye movements and pupillary reflex Sharp/dull discrimination or light touch Strength, coordination, and gait Level of consciousness and orientation Mental status Sensation Cranial nerves Motor function

Eye movements and pupillary reflex Cranial nerves Sharp/dull discrimination or light touch Sensation Strength, coordination, and gait Motor function Level of consciousness and orientation Mental status

Which part of the eye would the nurse palpate gently to assess for nodules or pain? A. Lens B. Eyelid C. Cornea D. Orbital bone

Eyelid The eyelids should be gently palpated to feel for nodules and pain.

Which question would the nurse ask to gather health history information about the patient's head and neck? A. Do you have a history of vertigo? B. Do you have a history of tonsillitis? C. Have you ever experienced dizziness? D. Have you experienced pain or discharge around your eyes?

Have you ever experienced dizziness? The nurse asks questions about dizziness when assessing the head and neck or the ears.

Match the type of health history content being gathered by the nurse to the appropriate question. Have you ever had any allergic skin reactions to food, drugs, or plants? Have you observed changes in the consistency, color, or texture of your nails? Has anyone in your family ever had skin cancer? Current health Family medical history Personal medical history

Have you ever had any allergic skin reactions to food, drugs, or plants? Personal medical history Have you observed changes in the consistency, color, or texture of your nails? Current health Has anyone in your family ever had skin cancer? Family medical history

When collecting information about the patient's current health status related to the cardiovascular system, which questions would the nurse ask? Select all that apply. A. Have you recently gained or lost weight? B. Are you experiencing chest pain? C. Do you have edema or swelling in your ankles? D. Have you ever had loss of consciousness or fainted? E. Have you been hospitalized for a cardiac event?

Have you recently gained or lost weight? Asking about any changes in weight provides relevant information about current health status that the nurse would gather during the cardiovascular assessment. Are you experiencing chest pain? Inquiring about chest pain provides relevant information about current health status that the nurse would gather during the cardiovascular assessment. Do you have edema or swelling in your ankles? When asking the patient about edema or swelling in hands, feet, or ankles during the cardiovascular assessment, the nurse is gathering relevant information about current health status.

Which member of the health care team can perform internal vaginal and prostate examinations? A. Registered nurse B. Health care provider C. Patient care technician D. Certified nursing assistant

Health care provider Health care providers, such as physicians and nurse practitioners, are licensed and trained to perform internal vaginal and prostate examinations.

Which event can result if a tourniquet remains in place for more than a minute during a venous blood draw? A. Hemolysis resulting in bruising. B. Inflammation resulting in tissue damage. C. Hemoconcentration resulting in erroneous blood values. D. 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.

Which assessment finding would the nurse expect when auscultating the lungs of a healthy adult? A. High-pitched, loud bronchovesicular sounds B. Low-pitched, soft sounds heard over the trachea C. Pursed-lip breathing by the patient during expiration D. High-pitched, loud sounds heard over the main stem bronchus

High-pitched, loud sounds heard over the main stem bronchus A high-pitched, loud sound is the expected breath sound in a healthy adult when auscultating over the area of the main stem bronchus.

In which position would the nurse place the female patient to examine the female genitalia? A. Sims B. Supine C. Fowler D. Lithotomy

Lithotomy The lithotomy position would be the proper patient position to provide an adequate examination of the female genitalia. Sims The Sims position is a side-lying position and will allow for proper examination of the rectum but will not provide for an adequate assessment of the female genitalia. Supine In the supine position, the patient lays flat on her back and is not appropriate. Fowler The Fowler position has the patient sitting with a pillow propping up the knees and would not be conducive for an adequate examination of the female genitalia.

Define Risk of Injury

Local anesthesia to throat with loss of swallow and gag reflexes

Which procedure calls for neurologic assessment of the patient to evaluate for complications? A. Esophagogastroduodenoscopy B. Bronchoscopy C. Bone marrow aspiration D. 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.

When examining the head and its associated structures, which unexpected findings would the nurse document? Select all that apply. A. Lumps B. Edema C. Lesions D. Symmetry E. Discoloration

Lumps The presence of lumps is an unexpected finding that should be documented by the nurse. Edema Edema is an unexpected finding that the nurse would document. Lesions The existence of lesions is an unexpected finding that the nurse would document. Discoloration Discoloration is an unexpected finding that the nurse should document.

Which potential findings would the nurse assess during the palpation phase of the musculoskeletal examination? Select all that apply. A. Masses B. Crepitus C. Tenderness D. Deep tendon reflexes E. Postural abnormalities

Masses The nurse assesses for masses during the palpation phase of the musculoskeletal examination. Masses are indicative of musculoskeletal problems. Crepitus Crepitus is a crackling or popping sound, and the nurse assesses for this during the palpation phase of a musculoskeletal examination. Tenderness The nurse assesses for tenderness during the palpation phase of the musculoskeletal examination.

Which aspects does the nurse assess while palpating the chest during the respiratory system assessment? Select all that apply. A. Respiratory rate B. Masses C. Skin moisture D. Front-to-back diameter E. Breathing effort

Masses The nurse palpates to assess for masses or tenderness. Skin moisture The nurse palpates to assess for skin moisture and temperature.

Define Pancentesis

Measure intake and output

Which component of the focused neurologic examination addresses emotional state? A. Sensation B.Mental status C.Motor function D. Cranial nerves

Mental status Assessment of mental status involves evaluation of level of consciousness, orientation, and emotional state.

Which components does the nurse assess during the musculoskeletal examination? Select all that apply. Mobility Bone disease Tendon injury Cartilage disorder Exercise level

Mobility Assessment of the musculoskeletal system includes information about the patient's mobility. Bone disease The nurse assesses diseases related to the musculoskeletal system during the examination. Tendon injury Assessment of musculoskeletal-related injuries is a component of the examination. Exercise level Assessment of the patient's exercise level is a component of the musculoskeletal system examination.

Which information would the nurse use to identify a patient before collecting a sample for diagnostic testing? Select all that apply. A. Name B. Date of birth C. Room number D. Home address E. 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.

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? A. Reschedule the examination. B. Document the information. C. Notify the health care provider. D. 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.

Which action would the nurse take if a patient accidently urinates into the stool collection container? A. Use the sample as is. B. Obtain a new sample. C. Send the sample after draining urine. D. 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 patient information would be communicated to the laboratory when collecting a clean-catch urine sample to avoid a false-positive result for hematuria? A. Patient is diabetic. B. Patient is menstruating. C. Patient has an enlarged prostate. D. 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. The rest is Incorrect Patient is diabetic. It is not necessary to document that a patient is diabetic when collecting urine to avoid a false-positive result for hematuria. Diabetes does not cause hematuria. Patient has an enlarged prostate. It is not necessary to document that a patient has an enlarged prostate when collecting urine to avoid a false-positive result for hematuria; an enlarged prostate does not cause hematuria. Patient is constipated. It is not necessary to document that a patient is constipated when collecting urine to avoid a false-positive result for hematuria; constipation does not cause hematuria.

Which outcome is applicable to a hypothesis of Anxiety? A. Flushing, itching, and urticaria are absent. B. Patient respirations are easy with a rate within an expected range. C. The patient remains free of injury related to the diagnostic procedure. D. The 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.

Which information must the nurse routinely verify as part of assessment before any diagnostic test? Select all that apply. A. Patient's history of allergies B. Patient's ethnic affiliation C. Patient's insurance coverage D. Patient's understanding of what is to be done E. 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 instrument would the nurse use to assess the pupillary reflexes? A. Penlight B. Otoscope C. Reflex hammer D. Tongue blade

Penlight A penlight is used to assess pupillary reflexes by flashing the light into the eyes.

Which aspect of cardiovascular function does the nurse assess when inspecting the skin and lower extremities? A. Apical pulse B. Peripheral pulses C. Peripheral perfusion D. Heart rhythm

Peripheral perfusion The skin and lower extremities are inspected for evidence of peripheral perfusion.

Which measures would the nurse take to avoid stimulating the patient's gag reflex when obtaining a throat culture? Select all that apply. A. Place swab off center. B. Swab the patient's throat quickly. C. Have patient gargle with viscous lidocaine. D. Ask the patient to sit upright and say, "Ahh." E. 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.

Before which diagnostic test would the nurse ask a question about breastfeeding? A. Magnetic resonance imaging (MRI) B. Computed tomography (CT) scan C. Positron emission tomography (PET) scan D. 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.

Which finding indicates a problem associated with bone loss, such as osteoporosis? Gross disfigurement Abnormal reflexes Postural abnormalities Decreased pulse strength

Postural abnormalities Postural abnormalities are indicative of bone loss or other musculoskeletal dysfunction. For example, height loss or stooped posture can result from osteoporosis.

To whom is the nurse responsible for communicating test results? A. Office staff B. Nurse coworker C. Laboratory manager D. 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 hypothesis is appropriate for a patient who has researched the planned procedure and requests time to clarify findings with the nurse? A. Anxiety B. Ready to Learn C. Lack of Knowledge of Diagnostic Test D. 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.

Match the skin assessment term to the appropriate description. Redness Yellow hue Lack of color Blue discoloration Erythema Pallor Cyanosis Jaundice

Redness Erythema Yellow hue Jaundice Lack of color Pallor Blue discoloration Cyanosis

Which additional body system would the nurse evaluate when assessing the cardiovascular and peripheral vascular systems? A. Respiratory B. Genitourinary C. Gastrointestinal D. Musculoskeletal

Respiratory The heart and lungs share a common circulatory system, such that a problem affecting the cardiovascular system can also affect the respiratory system.

Define Anxiety

Restless moving, rubbing fingers, and trembling voice

Which action allows the nurse to focus questions about the musculoskeletal system during the health history interview? A. Review of health records B. Organization of equipment C. Analysis of the review of systems D. Completion of the physical examination

Review of health records The review of health records provides information on any preexisting musculoskeletal problems. This knowledge assists the nurse in focusing questions during the health history interview and review of systems.

In which order would the nurse perform an assessment of the integumentary system. Review the patient's medical records for preexisting issues with skin, hair, or nails. Interview the patient to complete the general survey, health history, and review of systems. Complete physical examination of the skin, hair, and nails.

Review the patient's medical records for preexisting issues with skin, hair, or nails. Interview the patient to complete the general survey, health history, and review of systems. Complete physical examination of the skin, hair, and nails.

Which hypothesis is being addressed when the nurse verifies with a patient that required preparation for a diagnostic test was done? A. Anxiety B. Risk for Injury C. Risk for Anaphylaxis D. 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.

Which hypothesis is the immediate priority for a patient who is sedated before undergoing an invasive diagnostic procedure? A. Anxiety B. Ready to Learn C. Risk for Injury D. 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.

A patient is having a magnetic resonance imaging (MRI) scan of the pancreas with contrast. Which hypothesis is the priority for this patient? A. Drug Dependence B. Risk for allergic reaction C. Lack of Family Support D. 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. Drug Dependence Drug Dependence is a problem that could be life-threatening, but it is not as immediate as anaphylaxis on injection of the contrast medium. Lack of Family Support Lack of Family Support is not an immediate life-threatening problem. Lack of Trust in Health Care Provider Lack of Trust in Health Care Provider is not a life-threatening problem.

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. A. Prescribing B. Scheduling C. Collecting D. Handling E. Documenting

Scheduling The nurse is responsible for scheduling collection of specimens. Collecting The nurse is ultimately responsible for the collection of specimens even if the task is delegated. Handling The nurse is responsible for handling the specimens and ensuring they reach the laboratory for processing in a timely manner. Documenting The nurse is responsible for documentation related to the collection of specimens.

Which nerve does the nurse assess when applying dull and sharp stimuli to different areas of the body? A. Motor nerve B. Cranial nerve C. Sensory nerve D. Accessory nerve

Sensory nerve Sensory nerve information is assessed through the use of dull and sharp stimuli to check for normal reactions from such stimuli.

Which characteristics would the nurse assess while inspecting the chest during the respiratory system examination? Select all that apply. A. Shape B. Symmetry C. Tenderness D. Skin temperature E. Breathing pattern

Shape The nurse inspects the chest for symmetry. Symmetry The nurse inspects the chest for shape as well as front-to-back diameter. Breathing pattern The patient's breathing pattern is observed (rate, rhythm, depth, and effort) to ensure there is no shortness of breath or difficulty breathing.

Which part of the nose would the nurse palpate to assess for swelling, drainage, and tenderness? A. Nostrils B. Mucosa C. Sinuses D. Septum

Sinuses The nurse palpates the sinuses to assess for swelling, drainage, and tenderness during the physical examination of the nose.

Which techniques can be used to obtain a sputum sample if coughing alone is ineffective? Select all that apply. A. Suctioning B. Use of expectorants C. Saline lavage D. Chest percussion E. Use of an aerosol or nebulizer

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.

Which patient position enables the nurse to perform an examination of the gastrointestinal system? A. Sims B. Prone C. Supine D. Fowler

Supine The supine position would permit the examiner to perform an adequate examination of the gastrointestinal system. Sims Sims position is the appropriate position for an examination of the rectum but is not a good position for examination of the gastrointestinal system. Prone The examiner would have no access to the abdomen if the patient is in the prone position. Fowler The Fowler position is not a good position for an examination of the gastrointestinal system because of the shortened access to the abdomen.

Which components would the nurse assess during palpation of the skin? Select all that apply. A. Clubbing B. Swelling C. Skin texture D. Discoloration E. Skin temperature

Swelling Swelling should be assessed during the palpation phase of the examination. Skin texture Skin texture should be assessed during the palpation phase of the examination. Skin temperature Skin temperature should be assessed during the palpation phase of the examination.

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? A. Using the patient instruction sheet as a guide, the patient will explain how to carry out self-preparation for the cystoscopy procedure. B. The patient will ask questions about self-preparation for a cystoscopy after the nurse's explanation of what is to be done. C. The patient will be attentive while a member of the health care team explains the purpose of the procedure. D. 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.

Match the patient with the related difficulty in obtaining a blood sample. Veins too small Veins fragile, risk for bleeding Veins difficult to visualize and/or access Choice an option 3-month-old weighing 9 pounds 25-year-old weighing 350 pounds 86-year-old weighing 120 pounds

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 3-month-old weighing 9 pounds

Which unexpected findings from the abdominal assessment would the nurse document in the electronic health record and report to the health care provider? Select all that apply. A. Flat abdomen B. Visible protrusions C. Rebound tenderness D. Hyperactive bowel sounds E. Bowel sounds in all quadrants

Visible protrusions Visible protrusions are an unexpected finding and should be reported to the health care provider. Rebound tenderness Rebound tenderness is an unexpected finding and should be reported to the health care provider. Hyperactive bowel sounds Hyperactive bowel sounds are an unexpected finding and should be reported to the health care provider.

Which actions would the nurse take to protect self and others when drawing blood from a patient during a routine annual checkup? Select all that apply. Wear gloves. Wear a gown. Wear a mask. Double-glove. Dispose of sharps properly.

Wear gloves. The nurse must wear gloves to protect self from contact with blood. Dispose of sharps properly. The nurse must dispose of sharps in the proper container to protect self and others from accidental injury and contamination.

Define Bone marrow

aspirationMaintain bed rest for at least an hour

Which procedures require the patient to remain NPO (nothing by mouth) until the gag reflex returns? Select all that apply. A. Bronchoscopy B. Cystoscopy C. Colonoscopy D. Arthroscopy E. 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.

Which questions would the nurse typically ask a patient before sedation for a diagnostic procedure? Select all that apply. A. "Did you drink any alcohol within the last 24 hours?" B. "When was the last time you had anything to eat or drink?" C. "What was the date of your last visit to your primary health care provider?" D. "Can you tell me about the procedure you are having and ask any questions you may have about it?" E. "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. A. "When did you eat last?" B. "Do you get claustrophobic?" C. "Do you have any open wounds?" D. "Do you have a cardiac pacemaker?" E. "Are you wearing a watch or any jewelry?" F. "Do you have any metal objects in your body?"

"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.

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. A. "Have you monitored your glucose before?" B. "Has the diabetes educator seen you yet?" C. "Do you see yourself being able to check your blood glucose at the times prescribed?" D. "Are you able to buy your own glucometer, strips, and lancets?" E. "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.

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. A. "Do you take any prescription medications on a regular basis?" B. "Have you taken any antibiotics within the past month?" C. "Are you allergic to any medications?" D. "Do you take any herbal medications?" E. "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? A. "Lie on the affected side for at least an hour." B. "Do not eat or drink until your gag reflex returns." C. "Notify the nurse if you experience trouble breathing." D. "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.

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. A. "Tell me when you have the sample." B. "Please collect the urine sample as soon as possible." C. "Be sure the area around the urethral meatus is thoroughly cleaned." D. "Use a sterile specimen cup and make sure not to touch the inside of the cup or the cover." E. "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.

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.

Which time of day is best to collect a sputum sample? A. 07:00 B. 12:00 C. 16:00 D. 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.

When asked about allergies during a prediagnostic procedural assessment, a patient reports being allergic to codeine and penicillin. Which question is most important for the nurse to ask next? A. "What happens when you take these drugs?" B. "When was the last time you took one of these drugs?" C. "How much time passes between taking the drug and developing the allergic reaction?" D. "How much of these drugs do you need to take before you have an allergic reaction?"

A. "What happens when you take these drugs?"

The nurse associates abnormalities of the skin, hair, or nails with potential disorders of which systems? Select all that apply. A. Cardiac B. Sensory C. Neurologic D. Respiratory E. Hematologic

A. Cardiac Abnormalities of the skin, hair, or nails could be indicative of cardiac disorders. For example, clubbing is a physical sign characterized by bulbous enlargement of the ends of one or more fingers or toes caused by heart and lung diseases that reduce the amount of oxygen in the blood. D. Respiratory Respiratory Respiratory disorders may manifest as abnormalities of the skin, hair, or nails. For example, cyanosis is a blue discoloration of the skin caused by poor oxygenation. Nail clubbing is an example of an abnormality of the nails, which is indicative of a respiratory or cardiac disorder. E. Hematologic Skin pallor is consistent with anemia and ecchymosis is consistent with platelet dysfunction, both disorders of the hematologic system.

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? A. Ability to arrange for transport for a follow-up appointment with health care provider B. Previous experience with specimen collection C. Ability to follow the correct collection technique D. 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 components are included in the neurologic system? Select all that apply. A. Skull B. Brain C. Nerves D. Spinal cord E. Carotid artery

Brain The brain functions as the coordinating center of sensation, intellectual, and nervous activity and is a component of the neurologic system. Nerves Nerves transmit impulses of sensation to the brain or spinal cord and are a component of the neurologic system. Spinal cord The spinal cord helps form the central nervous system, which is a component of the neurologic syste

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. A. Ask what and how much the patient ate and drank. B. Reschedule the procedure. C. Notify the health care team. D. Document the information about the patient's eating and/or drinking. E. 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 actions would the nurse implement during auscultation of the cardiovascular system? Select all that apply. A. Listen at all three valves B. Evaluate for symmetry C. Assess rate and rhythm D. Feel for quality of pulses E. Use both sides of stethoscope

Assess rate and rhythm The nurse listens for the rate and rhythm of the apical pulse. Use both sides of stethoscope The nurse uses both sides of the stethoscope to assess for both low- and high-pitched sounds.

Which question would the nurse ask a patient who collects a urine specimen at home? Select all that apply. A. "Was the specimen left unattended for any length of time?" B. "At which temperature was the specimen maintained?" "Who collected the specimen?" C. "How quickly was the specimen transported?" D. "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.

When the nurse identifies clubbing of a patient's nails, which type of medical condition would the nurse suspect as the cause? A. Cardiac B. Neurologic C. Gastrointestinal D. Musculoskeletal

Cardiac Clubbing is a condition in which there is enlargement of the ends of one or more fingers or toes and is associated with decreased peripheral perfusion due to cardiac or respiratory problems.

Which anatomic structure would the nurse auscultate during the examination of the throat? A. Jugular veins B. Thyroid glands C. Carotid arteries D. Subclavian arteries

Carotid arteries Auscultation of the carotid arteries to assess blood flow would be included in an examination of the throat.

Define risk for anaphylaxis

History of itch and rash after eating shellfish as a child

Which steps performed before any specimen collection procedure are critical to patient safety? Select all that apply. A. Provide privacy. B. Identify the patient. C. Gather the equipment. D. Explain what is to be done to the patient. E. Notify the laboratory that the specimen will be arriving. F. Verify the health care provider's prescription for the specimen.

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.

Which descriptors would the nurse use in reference to changes in a patient's condition after an allergic reaction to contrast media? A. Critical, stable, or good B. Satisfactory or unsatisfactory C. Urgent, concerning, or reassuring D. 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.

Place the components of the gastrointestinal examination in the correct order. Auscultation Palpation Percussion Inspection

Inspection Auscultation Palpation Percussion

Which assessment technique would the nurse use during the neurologic assessment? A. Inspection B. Reflexology C. Percussion D. Auscultation

Inspection The nurse uses the assessment techniques of inspection and palpation during a neurologic examination.

Place the following steps of the sputum collection procedure in the appropriate order. Place sample in biohazard bag. Collect sample in a cup. Label the container. Provide oral care. Instruct patient to breathe deeply and cough.

Instruct patient to breathe deeply and cough. Collect sample in a cup. Label the container. Place sample in biohazard bag. Provide oral care.

In which areas would the nurse use a reflex hammer to assess for deep tendon reflexes? Select all that apply. A. Patellae B. Biceps C. Triceps D. Phalanges E. Achilles tendon

Patellae The patellae are assessed for deep tendon reflexes, and a normal reaction is extension of the leg. Biceps Biceps are checked for deep tendon reflexes, with a normal response being contraction and flexion. Triceps Triceps are part of the deep tendon reflex assessment, and the normal response should be extension of the forearm. Achilles tendon The Achilles tendon is assessed for deep tendon reflexes, with a normal finding being plantar flexion of the foot.

Which signs would the nurse recognize as indicative of an allergic reaction to a contrast medium? Select all that apply. A. Itching B. Urticaria C. Vomiting D. Abdominal pain E. 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.

Which techniques would the nurse utilize to auscultate the patient's chest during the respiratory assessment? Select all that apply. A. Listen for a full respiratory cycle. B. Use a systematic pattern. C. Assess at least two lobes. D. Feel for depth of breathing. E. Listen for unexpected sounds.

Listen for a full respiratory cycle. At each auscultation site, the nurse listens for a full respiratory cycle (inspiration and expiration). Use a systematic pattern. The breath sounds in each of the lobes of the lungs are auscultated using a systematic pattern. Listen for unexpected sounds. The nurse listens to each lobe for airflow and any unexpected sounds.

Which physical assessment findings related to the musculoskeletal system would the nurse report to the health care provider? Select all that apply. A. Pain B. Lesions C. Absence of crepitus D. Abnormal posture or gait E. Presence of deep tendon reflexes

Pain Pain is an unexpected finding that should be reported to the health care provider. Lesions Lesions are unexpected findings that the nurse should report to the health care provider. Abnormal posture or gait Abnormal posture or gait is an unexpected finding that should be reported to the health care provider.

Which signs would the nurse associate with arterial insufficiency? Select all that apply. A. Pallor B. Edema C. Paralysis D. Numbness E. Pulselessness

Pallor Pallor is a pale or lightened skin tone and can be caused by illness, emotional shock or stress, decreased exposure to sunlight, or anemia. Paralysis Paralysis is the inability to move and can be associated with arterial insufficiency. Numbness Numbness is part of the five P's of circulation (paresthesia) and is generally caused by damage to peripheral nerves, resulting in arterial insufficiency. Pulselessness Pulselessness is the lack of blood flow in the circulation of the large arteries and is a sign of arterial insufficiency.

Which techniques would the nurse use when assessing a patient's head, eyes, ears, nose, and throat? Select all that apply. A. Palpation B. Inspection C. Evaluation D. Percussion E. Auscultation

Palpation Palpation uses touch to assess for temperature, moisture, tenderness, lumps, lesions, masses, and swelling of the head, eyes, ears, nose, and throat. Inspection Inspection involves the use of vision and smell to closely scrutinize physical characteristics of the head, eyes, ears, nose, and throat. Auscultation Auscultation is used in the assessment of the head, ears, eyes, nose, and throat to assess the carotid arteries for bruits (abnormal sounds) to assess blood flow to the head.

Which assessment techniques would the nurse use during examination of the respiratory system? Select all that apply. A. Palpation B. Inspection C. Evaluation D. Percussion E. Auscultation

Palpation The chest and ribs are palpated to assess for masses or tenderness. Skin temperature and moisture are assessed, and the nurse feels for depth of breathing by placing the thumbs on either side of the spine and noting thumb movement. Inspection The chest is inspected for symmetry and shape as well as front-to-back diameter. The patient's breathing pattern is observed (rate, rhythm, depth, and effort) to ensure that there is no shortness of breath or difficulty breathing. Auscultation The breath sounds in each of the lobes of the lungs are auscultated using a systematic pattern. At each auscultation site, the nurse listens for a full respiratory cycle (inspiration and expiration). In each lobe, the nurse listens for airflow and any unexpected sounds.

Which physical assessment techniques would the nurse use during examination of the cardiac and peripheral vascular systems? Select all that apply. A. Palpation B. Inspection C. Interview D. Percussion E. Auscultation

Palpation The nurse palpates heart valve closures and the apical impulse between the ribs on the left chest wall to feel for the aortic vibrations in the epigastric area. The peripheral pulses are also palpated to determine the pulse rate, rhythm, quality, and symmetry. Inspection The nurse inspects the skin and extremities for evidence of diminished peripheral perfusion. Auscultation The nurse auscultates the heart at each of the four valves to determine blood flow through the chambers, using both sides of the stethoscope to assess for both low- and high-pitched sounds.

Which assessment techniques would the nurse use during the abdominal assessment? Select all that apply. A. Palpation B. Inspection C. Percussion D. Observation E. Auscultation

Palpation The nurse palpates the abdomen in each quadrant, starting with light pressure and then using deeper pressure. The nurse also palpates the bladder area. A palpable, firm bladder suggests that it is distended with urine. Inspection The nurse inspects the abdomen for discoloration, bruising, edema, lesions, stretch marks, and scarring. Bulges, distention, or protruding masses are also noted. Auscultation The nurse uses the diaphragm of the stethoscope to auscultate bowel sounds in all four quadrants of the abdomen.

Which assessment techniques would the nurse use when assessing the musculoskeletal system? Select all that apply. A. Palpation B. Inspection C. Percussion D. Observation E. Auscultation

Palpation The nurse palpates the muscles and bones, feeling for crepitus, tenderness, and masses. Inspection The nurse observes the ease with which the patient walks, moves, and changes positions.

Which techniques would the nurse utilize when assessing the integumentary system? Select all that apply. A. Palpation B. Inspection C. Percussion D. Auscultation E. Evaluation

Palpation The nurse palpates the skin, scalp, and nails during the integumentary system examination. Inspection The nurse inspects the skin, head, body hair, and nail beds throughout the integumentary system examination.

Which information would unlicensed assistive personnel (UAP) report to the nurse when performing blood glucose testing on a patient? Select all that apply. A. The patient showered and ambulated before the glucose test was done. B. The patient's blood glucose was 56 mg/dL. C. The required glucose tests have been completed. D. The patient is concerned about how many times a finger stick is performed. E. 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.