exam ch.23

The nurse is obtaining a throat culture. What area will the nurse swab with a cotton-tipped applicator? a.Larynx b.Oral mucosa c.Pharynx d.Trachea

ANS: C The nurse should swab the tonsillar area (pharynx) with a sterile cotton-tipped applicator to obtain a specimen for a throat culture.

The patient has undergone a lumbar puncture. What position will the nurse place the patient in for up to 12 hours to avoid discomfort from postpuncture spinal headache? a.Supine b.Lateral c.Sims d.Prone

ANS: A The nurse should place the patient in the supine position and keep in reclining position for 12 hours.

A patient in the outpatient clinic has provided a urine sample. To perform a urine dipstick test accurately, the nurse wets the dipstick and starts timing: a. immediately. b. after 5 seconds. c. after 10 seconds. d. after 30 seconds.

ANS: A The stick is inserted into the urine specimen and removed quickly, and timing is started immediately. It is tapped gently on the side of the container to remove excess urine.

What should the nurse do when preparing the patient for an arteriography? a.Verify if the patient has been taking anticoagulants b.Keep the patient NPO for 24 hours before the procedure c.Instruct the patient to have a full bladder for the procedure d.Inform the patient that a coldness may be felt when dye is injected

ANS: A When a patient has an arteriography, the nurse should assess if the patient has been taking anticoagulants. The patient is kept NPO for 2 to 8 hours before the procedure. The nurse informs the patient that a warm flush may be felt when dye is injected. The patient is instructed to void before the arteriography.

The physician has ordered the collection of a 24-hour urine specimen. The nurses instructions to the patient for proper collection of the urine specimen include: (Select all that apply.) a. keep the container refrigerated as needed. b. empty the bladder into the toilet and begin timing the collection. c. void a small amount of urine after external genitalia are cleansed. d. keep the container on ice if instructed to do so.e. save only the first voiding in the morning.

ANS: A, B, D When a 24-hour urine specimen is collected, the patient should be instructed to empty the bladder into the toilet and begin timing the collection of the specimen; to add all urine to the collection container for the next 24 hours; to keep the container on ice or refrigerated; and when the 24 hours are up, to empty the bladder and add the urine to the collection container and then seal it and send it to the laboratory.

The nurse is aware that the chart of a patient going for a cardiac catheterization should have: (Select all that apply.) a. a signed consent form. b. a complete history and physical examination. c. evidence of the initiation of NPO status at least 2 hours prior. d. evidence of patient teaching done before the consent form is signed. e. report of kidney function tests. f. administration of ordered preoperative medications.

ANS: A, B, D, F Patient teaching must be done before a signed consent form is initiated. A complete history and physical examination is done and NPO status is initiated at least 6 hours prior to the procedure. The patient is also given ordered preoperative medications.

The nurse is preparing to collect a urine specimen. What will this nurse include when labeling this specimen? (Select all that apply.) a.Date and time of collection b.Identification of last name only c.Room number d.Medical record number e.Insurance information

ANS: A, C, D When labeling a specimen date and time of collection, room number and medical record number should be included. Patient should be identified by full name. Insurance information is not necessarily included.

The nurse is aware that patients who are not candidates for magnetic resonance imaging (MRI) include patients with: (Select all that apply.) a. a hip prostheses. b. bleeding tendencies. c. allergy to iodine. d. cardiac pacemakers. e. previous radiological treatment.

ANS: A, D Patients with prosthetic hips and knees, implanted pacemakers, or metal clips or staples are not candidates for an MRI because of the magnetic field the test creates.

The nurse informs the patient who is to have an electroencephalogram (EEG) that the technician will try to stimulate seizure activity by asking the patient to: (Select all that apply.) a. close his eyes. b. hyperventilate. c. breathe in a rapid shallow fashion. d. hold a flashing light over his face. e. submerge his hands in cold water.

ANS: B, C, D During an EEG, abnormal brain activity can be stimulated by the patient being requested to hyperventilate, breathe rapidly with shallow breaths, and respond to a flashing light over his face.

What intervention should the nurse implement when preparing the patient for a glucose tolerance test (GTT)? a.Restrict water intake before the test b.Encourage water intake before the test c.Keep patient NPO 4 hours before the test d.Instruct patient to have a full bladder for the test

ANS: B A patient having a glucose tolerance test should be kept NPO for 12 hours before the test except for water consumption so that they can provide urine samples. The patient should empty their bladder before the examination

What type of stool specimen must be sent to the laboratory immediately? a.Occult blood b.Ova and parasites c.Infection d.Fats

ANS: B A stool specimen for the presence of ova or parasites must be taken to the laboratory immediately.

The nurse is preparing a patient for a barium enema. What color will the nurse inform the patient his stools will be following this procedure? a.Blue b.White c.Green d.Brown

ANS: B Immediately following a barium enema, a patient's stools are white until all of the barium is expelled.

The nurse explains that electrocardiograms are graphic representations of electrical impulses generated by the heart. What type of abnormalities can an electrocardiogram identify? a.Those that produce a cardiac cycle b.Those that interfere with electrical conduction c.Those that result from an interrupted blood flow d.Those that interfere with heart contraction

ANS: B Electrocardiograms identify abnormalities that interfere with electrical conduction.

A patient is scheduled to have a blood chemistry profile drawn at 8 AM tomorrow. The note should be added on the care plan and report provided to the oncoming shift to withhold food and drink after: a. 6 AM. b. 12 midnight tonight. c. 4 AM today. d. noon today.

ANS: B Food and drink are usually withheld for 8 to 12 hours before blood chemistry tests are performed.

What should the nurse encourage the patient to consume when preparing for an electroencephalogram (EEG)? a.Tea b.Food c.Cola d.Coffee

ANS: B Food intake should be encouraged, but coffee, tea, and colas should be eliminated before an EEG.

The nurse instructs an outpatient female patient preparing for an abdominal ultrasonography that prior to the procedure, she should: a. eat or drink nothing after midnight. b. drink a liter of water. c. empty the bladder fully. d. use enemas at home to clear the bowel fully.

ANS: B For abdominal ultrasonography, the patient is asked to drink a liter of water before the procedure. This helps change the echo-reflection pattern from the bladder, helping to better distinguish the bladder from the female reproductive organs that lie nearby.

The nurse has an order to perform occult blood testing on a patient's emesis. What color will the sample turn to indicate that the test is positive for occult blood? a.Red b.Blue c.Green d.Yellow

ANS: B If the sample turns blue, the test is positive for occult blood; if it turns green, it is negative for occult blood.

The statement made by a patient that would delay a scheduled CT scan would be: a. I have terrible claustrophobia. b. I have just been started on metformin. c. I am allergic to penicillin. d. I have an implanted pacemaker.

ANS: B Metformin should be discontinued before the test with an iodine-based contrast medium because metformin significantly alters renal function.

What should the nurse assess the patient for before administration of contrast media? a.Has been NPO b.Is allergic to iodine c.Has emptied the bladder d.Has taken medication

ANS: B The patient should always be assessed for allergies to iodine before administration of contrast media.

A patient who is to have a treadmill stress test at 11:00 AM today should not consume: a. toast and jam. b. coffee and cream. c. oatmeal and sugar. d. pancakes and syrup.

ANS: B The patient should avoid caffeine and smoking for 6 hours before the test, but may have a light meal 2 or more hours beforehand.

What should the nurse do when preparing the patient for an abdominal scan? a.Assess laboratory results only for liver function b.Assess patient for allergies to dye or shellfish c.Instruct patient to limit fluid intake immediately following procedure d.Instruct patient to be NPO for 1 hour before scan if contrast medium is used

ANS: B The patient should be assessed for allergies to dye or shellfish. When a patient has an abdominal scan, laboratory results should be assessed for kidney function. The patient should be instructed to be NPO for 4 hours before the examination if contrast medium is to be used. The patient should be encouraged to consume fluids after the examination.

For the patient who just had a liver biopsy performed, the nurse should position him: a. prone for 1 hour. b. on his right side-lying for 2 hours. c. supine for 3 hours. d. on his left side-lying for 4 hours.

ANS: B The patient should be turned onto the right side for 2 hours after the procedure to minimize bleeding from the site

The nurse preparing a patient for a magnetic resonance imaging (MRI) should determine if the patient has: a. respiratory allergies. b. claustrophobia. c. fear of the dark. d. dizziness.

ANS: B The patient with claustrophobia can be reassured that there are methods to contact persons outside the cylinder.

A patient is required to provide a sample of body excretions per physician order. What action can the nurse take when providing proper instructions to lessen the patient's embarrassment? a.Instruct patient to provide the specimen behind a screen. b.Instruct patient to obtain his or her own specimen. c.Instruct patient to return later when he or she is more comfortable. d.Instruct patient to use a CNA for assistance to obtain the specimen.

ANS: B With proper instruction, many patients may obtain their own specimen.

What is the term for the cleanest part of a voided urine specimen that is collected after voiding is initiated and before it is finished?a.Sterile specimen b."Caught" specimen c.Midstream specimen d.Patient-collected specimen

ANS: C A midstream urine specimen is collected after voiding is initiated and before it is completed.

What role is the nurse who diligently works for the protection of patients' interests playing? a.Caregiver b.Health care administrator c.Advocate d.Health care evaluator

ANS: C A nurse accepts the role of advocate when, in addition to general care, the nurse protects the patient's interests. Caregiver, health care administrator, and health care evaluator are not terms for the nurse who diligently works for the protection of patients.REF: Page 24

What should the nurse do when preparing the patient for an exercise tolerance test (treadmill)? a.Withhold all foods and fluids before the test b.Withhold all heart medications before the test c.Allow the patient to drink water before the test d.Allow the patient to consume food before the test

ANS: C A patient having an exercise tolerance test is kept NPO, except for water, for 4 hours until after the test. The nurse should never withhold the patient's heart medications before this test.

What should the nurse do when preparing the patient for a brain scan? a.Allow the patient to wear a wig during the scan b.Allow the patient to wear a partial denture plate during the scan c.Inform the patient that a clicking noise will be heard during the scan d.Keep the patient NPO for 12 hours before scan if contrast dye is used

ANS: C Before a brain scan, the patient is kept NPO for 4 hours if contrast dye is to be used, the patient is instructed not to wear a wig, hairpins, clips, or partial denture plates, and the nurse informs the patient that a clicking noise is made as the scanner moves.

A sputum specimen is ordered on a patient diagnosed with pneumonia. When is the best time for the nurse to the attempt to collect this specimen? a.At bedtime b.After lunch c.In the early morning d.After breakfast

ANS: C Early morning before a meal is the best time to collect a sputum specimen

New physician orders are transcribed for a patient to receive a colonoscopy. What must be completed before the colonoscopy to indicate the patient has been given full knowledge about what will be done along with its risks and complications? a.Patients' rights b.Advance directive c.Informed consent d.Patient pro

ANS: C Informed consent states that the patient must fully understand and be aware of the risks and complications of what is to be done.

The nurse is caring for a patient following a bronchoscopy and maintains NPO status for 2 hours. What additional assessment will indicate to the nurse that this patient's risk for aspiration has decreased? a.Patient is fully awake b.Patient asks for a drink c.Gag reflex has returned d.Preoperative medication has worn off

ANS: C The nurse should not allow the patient to eat or drink after a bronchoscopy until the gag reflex has returned

What health care professional has the responsibility for notifying the physician when laboratory and diagnostic studies deviate from the norm? a.Laboratory technician b.Cooperating physician c.Nurse d.Supervisor

ANS: C It is the nurse's responsibility to notify the physician when laboratory and diagnostic studies deviate from the norm.

Prior to the nurse transporting the patient to have a magnetic resonance imaging (MRI), it is essential that the nurse confirm that the patient: a. has eaten a meal. b. has drunk a liter of fluid. c. is not wearing anything with metal. d. has a Foley catheter in place.

ANS: C Nursing care before an MRI involves obtaining consent and ensuring that all metal is removed from the patients body, because the machine emits a strong magnetic field.

A patient is unable to obtain a sputum specimen by coughing and expectorating. What is the best way for the nurse to collect this specimen? a.Ask the patient to spit b.Direct the patient to turn, cough, and breathe deeply c.Perform tracheal suctioning d.Perform a bronchoscopy

ANS: C Some patients cannot expectorate and must have the trachea suctioned to obtain a specimen.

What are the universal guidelines that define appropriate measures for all nursing interventions? a.Scope of practice b.Advocacy c.Standard of care d.Prudent practice

ANS: C Standards of care define actions that are permitted or prohibited in most nursing interventions. These standards are accepted as legal guidelines for appropriateness of performance.

What is the best way for a nurse to avoid a lawsuit? a.Carry malpractice insurance b.Spend time with the patient c.Provide compassionate, competent care d.Answer all call lig

ANS: C The best defense against a lawsuit is to provide compassionate and competent nursing care. Carrying malpractice insurance is prudent, but it will not avoid a lawsuit. Spending time with patients and answering call lights quickly will not necessarily help avoid a lawsuit.

The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed? a.Physical assessment b.Interview c.Informed consent d.Surgical checklist

ANS: C The doctrine of informed consent refers to full disclosure of the facts the patient needs to make an intelligent (informed) decision before any invasive treatment or procedure is performed. A physical assessment, interview, and surgical checklist are not required before this procedure.

A major concern for an 86-year-old patient who has been NPO for 8 hours prior to a diagnostic test would be: a. fatigue. b. circulatory status. c. hydration status. d. nutritional status.

ANS: C The elderly who are kept on an NPO status for prolonged periods of time are susceptible to dehydration and electrolyte imbalances.

When asked to perform a procedure that the nurse has never done before, what should the nurse do to legally protect himself or herself? a.Go ahead and do it b.Refuse to perform it, citing lack of knowledge c.Discuss it with the charge nurse, asking for direction d.Ask another nurse who has performed the procedure

ANS: C The nurse cannot use ignorance as an excuse for nonperformance. The nurse should ask for direction from the charge nurse, explaining she has never performed the procedure independently.

When a nurse protects the information in a patient's record what ethical responsibility is the nurse fulfilling? a.Privacy b.Disclosure c.Confidentiality d.Absolute secrecy

ANS: C The nurse has an ethical and legal duty to protect information about a patient and preserve confidentiality. Some disclosures are legal and anticipated, and may not be subject to the rules of confidentiality. None of the information in a chart is considered secret.REF: Page 28

The nurse is preparing a patient for a diagnostic examination. What can the nurse implement to assist with reducing anxiety? a.Explain the costs of the examination b.Demonstrate use of equipment c.Answer questions for clarification d.Fill out required paperwork

ANS: C The nurse must be prepared to answer questions that the patient may have to reduce anxiety and give valid information.

Following a liver biopsy, the nurse should observe for hemorrhage and ensure that the patient is kept on bed rest for 24 hours. How should the nurse keep the patient for the first 1 to 2 hours? a.On his or her left side b.On his or her back c.On his or her right side d.In high Fowler position

ANS: C The nurse should keep the patient on his or her right side for 1 to 2 hours.

What is the rationale for the nurse to assess a patient's knowledge of an ordered procedure? a.To determine difficulties the patient may encounter b.To determine the nurse's role in the procedure c.To determine health teaching required d.To determine anxiety the patient has

ANS: C The nurse will need to assess the patient's knowledge of the procedure to determine the level of health care teaching needed.

The process for collecting a blood specimen for measuring blood glucose levels begins by asking the patient to hold the selected arm at his or her side for 30 seconds. From what anatomic location is the specimen obtained? a.Tip of the finger b.Cubital fossa c.Side of the finger d.Center of the thumb

ANS: C The specimen should be collected from the side of the selected finger to avoid painful fingertip sticks.

Anaerobic organisms tend to grow within body cavities. What will the nurse use to collect an anaerobic specimen? a.Sterile cotton applicator b.Sterile culture tube c.Sterile syringe tip d.Sterile glass rod

ANS: C To collect an anaerobic specimen deep in a body cavity, the nurse uses a sterile syringe tip.

When obtaining a capillary blood sample for blood glucose, the nurse will select the puncture site to cause the least amount of discomfort, which is: a. the end of the index finger. b. the ball of the third finger. c. at right angles to the fingerprint lines. d. the ball of the thumb.

ANS: C Using the right angle to the fingerprint lines places the puncture on the side of the finger rather than on more sensitive areas.

What should the nurse do when preparing the patient for an amniocentesis? a.Restrict food intake b.Restrict fluid intake c.Monitor fetal heart tones d.Inform patient results will be available immediately

ANS: C When a patient has an amniocentesis, fetal heart tones should be monitored. There are no fluid or food restrictions, and the patient should be told to contact her physician to obtain results, which are usually available after 2 weeks

What is the probable source of bright red blood in the stool?a.Stomach b.Small intestine c.Lower gastrointestinal tract d.Higher intestinal trac

ANS: C When blood in the stool is bright red, the site of bleeding is most likely from the lower gastrointestinal tract.

The nurse should administer Telepaque in preparation for a cholecystogram. How frequently will the nurse administer one tablet of Telepaque before this procedure? a.Every 5 minutes b.Every 10 minutes c.Every 15 minutes d.Every 20 minutes

ANS: C Telepaque should be taken one at a time, waiting 15 minutes after each tablet.

What should the nurse do when preparing the patient for a bone scan? a.Sedate the patient b.Restrict food intake c.Restrict fluid intake d.Encourage water intake

ANS: D Before a bone scan, the patient is encouraged to drink several glasses of water. No fasting or sedation is required before a bone scan.

The patient is to be catheterized for residual urine. The nurse must perform this catheterization within how many minutes following voiding? a.40 minutes b.30 minutes c.20 minutes d.10 minutes

ANS: D Catheterization is performed within 10 minutes of the patient voiding to check for residual urine.

The procedure for collecting a sterile urine specimen via a catheter port includes clamping the Foley catheter tubing below the catheter port. How long will the clamp remain in place? a.5 minutes b.10 minutes c.20 minutes d.30 minutes

ANS: D Clamp just below the catheter port for 30 minutes.

A patient asks why the blood glucose meter directions state to wipe away the first drop of blood. The most informative response by the nurse would be: a. This eliminates microorganisms from the sample. b. The first drop is usually too small. c. The first drop is usually contaminated. d. The first drop has serous fluid that can dilute the specimen.

ANS: D Some machines state to wipe away the first drop of blood, which often contains a large portion of serous fluid that can dilute the specimen, causing a false result.

The nurse is collecting a specimen for a wound culture. What should be avoided when collecting this specimen? a.A dressing b.Deep in the wound c.The outer edge of the wound d.Old drainage

ANS: D The nurse should not collect a wound culture from old drainage.

What should the nurse do when preparing the patient for a bronchoscopy? a.Instruct the patient to hold his or her breath during the procedure b.Instruct the patient to remain NPO 24 hours before the procedure c.Obtain informed consent after premedicating the patient d.Reassure the patient that he or she will be able to breathe during the procedure

ANS: D The nurse should reassure a patient before a bronchoscopy that they will be able to breathe during the procedure. The patient is instructed to remain NPO after midnight (4 to 8 hours) before the procedure. Informed consent must be obtained before the patient is premedicated.

A patient has just had a liver biopsy. What should the nurse do immediately following this procedure? a.Assist the patient up to a chair b.Keep the patient on his or her left side c.Assist the patient with ambulation d.Tell the patient to avoid coughing

ANS: D The nurse should tell the patient to avoid coughing or straining, which may cause increased intra-abdominal pressure. Immediately following a liver biopsy, the patient is kept on bed rest for 24 hours. The patient should lie on his or her right side for about 1 to 2 hours.

The nurse obtaining a wound culture would: a. use clean gloves. b. rotate the swab vigorously in the wound bed. c. rinse the exudate on the swab with normal saline. d. place the swab in the culture tube without touching the sides.

ANS: D The nurse should use sterile gloves, rotate the swab gently in the wound bed, and place it directly into the culture tube without touching the sides of the tube.

A patient who has undergone endoscopy is fully awake and asks the nurse for something to drink. After confirming that liquids are allowed on the physician order sheet, the nurse should: a. assist the patient to the bathroom to void. b. listen to lung sounds. c. take a blood pressure and pulse. d. check for the return of gag and swallow reflexes.

ANS: D The patient should take nothing by mouth until the effects of local anesthesia have worn off and airway protective reflexes (such as gag and swallow reflexes) have returned.

The nurse instructing in the collection of a midstream urine catch would tell the patient to first cleanse the external genitalia and then to: a. begin voiding into the specimen cup. b. let a few drops of urine dribble into the specimen cup. c. void until the bladder is almost empty and then collect the end portion of the voiding in the cup. d. pass a small amount of urine into the toilet and then collect the specimen.

ANS: D To collect a midstream specimen, the external genitalia are cleansed, a small amount of urine is passed, and then a midportion of the voiding is collected in a sterile container and used for a culture.

A lumbar puncture was performed on a patient without a signed informed consent form. This patient might sue for: a.punitive damages. b.civil battery. c.assault. d.nothing; no violation has occurred.

ANS:B Civil battery charges can be brought against someone performing an invasive procedure without the patient's informed consent legally documented. This patient could not sue for punitive damages or an assault.