foundations Acid-Base to Diagnostic Test

The nurse is caring for a client with suspected kidney failure. A 24-hour urine specimen is prescribed. What value, which measures overall kidney function, will the nurse specifically plan to check?

Creatinine clearance levels

The nurse notes that the primary health care provider has documented a suspected diagnosis of herpes zoster in the client's chart. The nurse would prepare the client for which diagnostic test to confirm this diagnosis?

Culture of the lesion

The nurse is caring for a client after pulmonary angiography with catheter insertion via the left groin. Which assessment finding is related to an allergic reaction to the contrast medium?

Decreased blood pressure

A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse monitoring this client would expect to note which signs/symptoms?

Decreased respiratory rate and depth

A client suspected of having kidney stones is scheduled for an intravenous pyelogram. Before the test, which is the priority nursing action?

Determine a history of iodine allergy.

The nurse working in a same-day procedure unit is admitting a client scheduled for an arthrogram using a contrast medium. Which is the priority nursing assessment for this client?

Determine if the client has an allergy to iodine or shellfish.

The nurse working in the outpatient radiology department is giving discharge instructions to a client who has had a bone scan. Which instruction would the nurse include in the client's teaching plan?

Drink extra water for a day or so after the procedure.

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client's respiratory status would avoid which action?

Encouraging the client to breathe slowly and shallowly

The nurse is developing a plan of care for a client who has undergone an esophagogastroduodenoscopy procedure. The nurse would include which intervention in the nursing care plan?

Ensure that a gag reflex is present before allowing the client any oral intake.

A client has just returned to a nursing unit following bronchoscopy. Which nursing intervention would the nurse implement?

Ensuring the return of the gag reflex before offering food or fluids

The nurse is caring for a client admitted with a diagnosis of systemic lupus erythematosus (SLE). A highly sensitive C-reactive protein (hsCRP) blood test is prescribed. What other blood test is often used along with the hsCRP?

Erythrocyte sedimentation rate (ESR)

Which essential role does the nurse play in the health care team with multiple primary health care providers and specialists?

Facilitates communication among the team

A client with gallbladder disease is scheduled for oral cholecystography. For the evening meal prior to the test, the nurse would plan to provide a list of foods from which diet type?

Fat-free

The nurse is assisting the primary health care provider in performing a lumbar puncture on a client. The nurse prepares the client for the procedure by placing the client in which position?

Fetal

The nurse is admitting a client with cirrhosis of the liver and suspected ascites. What radiology films would initially be prescribed to diagnose ascites? Select all that apply.

Flat plate of the abdomen Kidney ureters bladder (KUB) Plain film Scout film

The nurse is preparing to obtain a sputum specimen from a client. Which nursing action will facilitate obtaining the specimen?

Having the client take 3 to 4 deep breaths

A client with an intervertebral disc problem is scheduled for myelography. Following myelography, how would the nurse plan to best position the client?

Head slightly elevated

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder?

Headache, restlessness, and confusion

The nurse collects a 24-hour urine specimen for catecholamine testing from a client with suspected pheochromocytoma. The results of the catecholamine test are reported as epinephrine 20 mcg (109 nmol) and norepinephrine 100 mcg (590 nmol). The nurse would make which interpretation about this result?

Higher than normal, indicating pheochromocytoma

A client is determined by blood gas analysis to be in respiratory alkalosis. Which electrolyte disorder would the nurse monitor for that could accompany the acid-base imbalance?

Hypokalemia

An adult client suspected of having leukemia is scheduled for bone marrow aspiration. The nurse prepares the client knowing that which possible site could be used for obtaining the bone marrow?

Iliac crest

The nurse is providing instructions to a client who has had a bone scan. The nurse would instruct the client to take which measure?

Increase fluid intake for the next 24 to 48 hours.

Cardiac magnetic resonance imaging (MRI) is prescribed for a client. When providing teaching, what does the nurse include as one of the major advantages of this test?

It doesn't require any radiation.

The nurse enters a client's room with a pulse oximetry machine and tells the client that the primary health care provider (PHCP) has prescribed continuous oxygen saturation readings. The client's facial expression changes to one of apprehension. The nurse can alleviate the client's anxiety by providing which information about pulse oximetry?

It is painless and safe.

A client experiencing metabolic acidosis is to be admitted to the nursing unit. The nurse plans care, knowing that what reaction is the most powerful regulator of acid-base balance?

Kidney

The nurse assists a primary health care provider in performing a lumbar puncture on a 3-year-old child with leukemia in whom central nervous system disease is suspected. In which position will the nurse place the child during this procedure?

Lateral recumbent position with the knees flexed and chin resting on the chest

The client with lung cancer and a right-sided pleural effusion seen on chest x-ray is being prepared for a thoracentesis. The nurse would assist the client to which position for the procedure?

Left side-lying position, with the head of the bed elevated 45 degrees

A client's blood gas results reveal acidosis. What are some signs and symptoms the nurse would expect to see? Select all that apply.

Lethargy Headache Weakness Confusion

A client is scheduled to have a needle liver biopsy. During the procedure, the nurse would instruct the client to take which action?

Lie supine with the right arm over the head.

An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder?

Light-headedness and paresthesias

The emergency department nurse is caring for a client with a suspected diagnosis of meningitis. The nurse would prepare the client for which test to confirm the diagnosis?

Lumbar puncture

A client with exacerbation of heart failure is being prepared for a thoracentesis. The nurse would assist the client to which position for the procedure?

Lying in bed on the unaffected side

The nurse is providing instructions to the client with lung cancer scheduled for magnetic resonance imaging who is suspected of brain metastasis. Which instruction would the nurse provide to the client?

Lying still in a flat position for 45 to 60 minutes may be necessary.

The nurse is planning care for a client who has just returned to the nursing unit after an oral cholecystogram. The nurse would expect to delete which prescription on the client's care plan?

Maintain a clear liquid diet for 72 hours.

A client with diabetes mellitus has a blood glucose level of 644 mg/dL (35.7 mmol/L). The nurse plans care, knowing that the client is at risk for the development of which type of acid-base imbalance?

Metabolic acidosis

A client with diabetes mellitus is most likely to experience which type of acid-base imbalance as a complication of the disorder?

Metabolic acidosis

The nurse is caring for a client with hyperglycemia and diabetic ketoacidosis (DKA) who now has developed Kussmaul's respirations. The nurse plans care, understanding that the purpose of this type of breathing is to correct what imbalance?

Metabolic acidosis

The nurse is caring for a client with a peptic ulcer who has just undergone an esophagogastroduodenoscopy (EGD). Which client problem would be the priority?

Risk for choking and aspiration related to a poor gag reflex postprocedure

A clinic nurse is reviewing the record of a client with a suspected diagnosis of pernicious anemia. The nurse anticipates that which diagnostic test will be prescribed by the client's primary health care provider?

Schilling test

The nurse is caring for a client who is experiencing metabolic alkalosis. Knowing the risks of this imbalance, the nurse plans to protect the client's safety by carefully implementing which prescribed precaution?

Seizure precautions

The nurse provides instructions to a client who is scheduled for an electroencephalogram. Which statement by the client indicates a need for further instruction?

"All medications need to be withheld on the day of the test."

Which statement would the nurse initially make to a client who is anxious about having a magnetic resonance imaging test?

"Can you tell me what you know about this test?"

A client asks the nurse to explain what is involved in an intravenous fluorescein angiography study of the eye. The nurse would incorporate which statement in the reply?

"Dilating drops will be instilled before the procedure."

The client with a history of chronic lung disease is at risk for developing respiratory acidosis. The nurse asks this client about which symptoms that are characteristic of this disorder?

"Do you have a headache or become confused?"

The nurse is providing information to a client about a computed tomography (CT) scan of the head. Which statement would the nurse include when reviewing preparation for the CT with the client?

"Each set of head scans takes less than 5 minutes to perform."

The ambulatory care nurse is providing home care instructions to the client after an arthroscopy of the knee. Which statement by the client indicates a need for further instruction?

"I can apply heat to the site if it becomes uncomfortable."

A client with a suspected intervertebral disc problem requires a myelogram, and the ambulatory care nurse is providing instructions to the client regarding preparation for the procedure. Which statement by the client indicates a need for further instruction?

"I need to be sure to eat a full meal before the procedure."

The nurse instructs a client suspected of having a urinary tract infection to obtain a clean-catch urine specimen for culture and sensitivity testing. Which statement by the client indicates that the client understands the procedure for collecting the specimen?

"I need to cleanse the labia using cleansing towels, void into the toilet, and then void into the sterile specimen container."

The nurse is providing instructions to a client suspected of having lymphoma who is scheduled for a gallium scan. Which statement made by the client indicates an understanding of the instructions?

"I need to have an injection 2 to 3 hours before the procedure."

The nurse has taught the client with suspected gallbladder disease about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement?

"I'm glad I don't have to lie still for this procedure."

The nurse is giving client instructions over the telephone about preparing for a mammography. The nurse would make which statement to the client?

"If possible, avoid using underarm deodorant on the day of the test."

A female client is scheduled to have a chest radiograph. Which question is most important for the nurse to ask when assessing this client?

"Is there any possibility that you could be pregnant?"

The primary health care provider (PHCP) tells a client that a blood transfusion is needed and that a blood sample must be drawn first for blood typing and crossmatching. The nurse explains to the client what a typing and crossmatch test is for and why it is done. What response by the client about blood typing implies to the nurse that further teaching is needed?

"It is an antibody found on the surface of the red blood cell."

The nurse is providing information to a client with myasthenia gravis who is scheduled for an electromyogram. Which statement by the client indicates the teaching has been effective?

"Needles will be inserted into the skeletal muscles."

The nurse is giving postprocedure instructions to a client returning home after arthroscopy of the shoulder. What is the priority instruction for this client?

"Report any fever or redness and heat at the site to your primary health care provider."

The nurse explains to a client why telemonitoring is needed. What response by the client indicates a need for further instruction?

"Telemonitoring ignores artifact."

A client is scheduled for a digital subtraction angiography study. After being provided information and instructions regarding the test, which statement by the client indicates that the teaching has been effective?

"The purpose of the test is to provide information about the blood vessels."

A client is being scheduled for a positron emission tomography (PET) scan of the brain. The nurse would provide which explanation to the client?

"The test detects abnormal glucose metabolism in the brain."

A young adult client has never had a chest x-ray before and expresses to the nurse a fear of experiencing some form of harm from the test. Which statement by the nurse provides valid reassurance to the client?

"The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation."

The clinic nurse has provided instructions to a client who will be reporting to the laboratory the next morning to have blood drawn for a complete blood cell count. Which statement made by the client indicates an understanding of the preparation for this laboratory test?

"There is no special preparation for this test."

The nurse is caring for a client with possible cholelithiasis who is being prepared for intravenous cholangiography and is teaching the client about the procedure. Which statement indicates that the client understands the purpose of this test?

"They are going to look at my gallbladder and ducts."

A client is about to have arterial blood gases drawn, and the nurse explains what an Allen's test is. What comment shows that the client understands the nurse's explanation?

"This test is done to make sure my circulation is good."

The nurse is explaining to a client what electroencephalography (EEG) involves. What response by the client indicates that further teaching is needed?

"This test is minimally invasive."

The nurse is explaining to an older client about a creatinine clearance test that has been prescribed. What response by the client indicates that there is a need for further teaching?

"This test measures the levels of all of the medications that I take."

An ultrasound examination of the gallbladder is scheduled for a client with a suspected diagnosis of cholecystitis. Correct instructions about the procedure would include which statement made by the nurse?

"This test requires that you lie still for short intervals."

A client with type 2 diabetes mellitus presents to the primary health care provider's office with a glycosylated hemoglobin (HgbA1C) level of 10.5%. Which statement by the client indicates an understanding of this test and its results?

"Well, I have 3 months to really work on watching my diet and lowering my blood sugar. My next glycosylated hemoglobin test will be better then."

The nurse has a prescription to obtain an arterial blood sample from a client. Prior to the procedure the nurse assesses the adequacy of the client's radial artery by performing the Allen's test. In which order would the Allen's test be performed? Place in correct order of priority. All options must be used.

1. Explain the procedure to the client. 2. Apply pressure over the ulnar and radial arteries simultaneously. 3. Ask the client to open and close the hand repeatedly. 4. Release pressure from the ulnar artery while compressing the radial artery. 5. Assess the color of the extremity distal to the pressure point. 6. Document the findings.

The nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen's test on the client. The nurse would perform the steps in which order to conduct an Allen's test? Arrange the actions in the order that they would be performed. All options must be used.

1. Explain the procedure to the client. 2. Apply pressure over the ulnar and radial arteries. 3. Ask the client to open and close the hand repeatedly. 4. Release pressure from the ulnar artery. 5. Assess the color of the extremity distal to the pressure point. 6. Document the findings.

A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure?

Side-lying with the legs pulled up and the head bent down onto the chest

The nurse is caring for a client who is scheduled for a liver biopsy. What is the priority order of actions for the nurse to take for the procedure? All options must be used.

1. Explain the procedure to the client. 2. Ensure that informed consent has been obtained. 3. Position the client supine, with the right side of the upper abdomen exposed; the client's right arm is raised and extended behind the head. 4. Remain with the client throughout the procedure. 5. Assist the client into a right lateral (side-lying) position, and place a small pillow under the puncture site. 6. Monitor vital signs closely and monitor for signs of bleeding.

The nurse is caring for a client undergoing a paracentesis. Place the preprocedure, during the procedure, and postprocedure nursing actions in order of priority. All options must be used.

1. Obtain informed consent. 2. Obtain vital signs and weight, and have client empty bladder. 3. Position the client upright. 4. Monitor blood pressure and pulse and maintain client on bed rest. 5. Document amount of fluid removed. 6. Document the event and the client's response.

The nurse is told to draw an arterial blood gas sample with the client on ambient air. The nurse documents in the record that the client was receiving how much oxygen for this procedure?

21%

The nurse is caring for a client who had intracranial surgery and is now suspected of having developed diabetes insipidus (DI). What initial prescription would the nurse expect from the primary health care provider (PHCP)?

24-hour fluid intake and output without restricting food or fluid intake

The nurse is explaining an upper gastrointestinal series to a client and provides the client with the preprocedure and postprocedure instructions. The nurse informs the client that after this procedure, the stools can be expected to remain white for what time period?

3 days

A fasting blood glucose screening test is performed on a pregnant client. The results indicate that the blood glucose level is 140 mg/dL (8 mmol/L). The nurse would anticipate that which treatment measure would most likely be prescribed next for the client?

A 3-hour glucose tolerance test

The ambulatory care nurse is providing instructions to a client who is scheduled for a colonoscopy and possible removal of a polyp. Which instructions are appropriate for client preparation for this procedure?

A bowel preparation will be needed in preparation for the procedure.

The clinic nurse is providing instructions to a client who is scheduled for a barium enema. What instruction would the nurse provide to the client in preparation for this procedure?

A low-fiber diet needs to be maintained for 1 to 3 days before the test.

The nurse assists a primary health care provider in performing a liver biopsy in a client suspected of having liver cancer. After the biopsy, the nurse would place the client in which position?

A right side-lying position with a small pillow or folded towel under the puncture site

A client with urolithiasis is scheduled for extracorporeal shock wave lithotripsy. The nurse would tell the client that which will be necessary before the procedure is performed?

A signed informed consent form

The nurse is providing information to a client suspected of having meningitis who is scheduled for a lumbar puncture. Which information would the nurse provide to the client?

A signed informed consent form will be required.

A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse would plan to carry out which prescribed measure as the most effective means to treat the problem?

Administer prescribed antibiotics.

The nurse is caring for a client who is going to have arthrography with a contrast medium. Which assessment by the nurse would be of highest priority?

Allergy to iodine or shellfish

The nurse is preparing a client who is scheduled to undergo cerebral angiography. The nurse would assess the client for which finding?

Allergy to iodine or shellfish

A client with a 3-day history of nausea and vomiting and suspected gastroenteritis presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn, and the nurse reviews the results, expecting to note which finding?

An increased pH and an increased HCO3-

The nurse is providing care to a client with the following arterial blood gas results: pH of 7.50, Pao2 of 90 mm Hg, Paco2 of 40 mm Hg, and bicarbonate of 35 mEq/L. When the nurse notifies the primary health care provider about these levels, the nurse would anticipate receiving from the PHCP which prescription for this client?

Discontinue nasogastric suctioning.

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?

An increased pH and an increased HCO3-

The nurse is caring for a client who is suspected of having meningitis and who is scheduled to have a lumbar puncture (LP). What are some contraindications for a client to have an LP? Select all that apply.

Clients with infection near the LP site Clients with increased intracranial pressure Clients receiving anticoagulation medications Clients who have severe degenerative vertebral joint disease

A quantitative 72-hour fecal fat collection is prescribed by the primary health care provider. How would the nurse instruct the client to prepare for the specimen collection?

Consume a high-fat diet for 3 days before the test.

The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit who is receiving nasal oxygen and notes a pH of 7.38, Paco2 of 38 mm Hg, Pao2 of 86 mm Hg, and HCO3 of 23 mEq/L. What action would the nurse take in response to these results?

Continue to monitor the client.

The nurse is performing a change-of-shift assessment on a client. The client had an arterial blood gas specimen drawn during an admission workup on the previous day and has a hematoma at the puncture site. What is the priority nursing intervention?

Apply a warm compress.

The nurse is planning to obtain blood for arterial blood gas analysis from a client with chronic obstructive pulmonary disease. The nurse would plan time for which activity after the arterial blood specimen is drawn?

Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes

The nurse is providing directions to a client about how to test a stool for occult blood. The nurse cautions the client that which could cause a false-negative result?

Ascorbic acid

A computed tomography scan of the chest with contrast is scheduled to be performed in a client suspected of having a pulmonary embolism. In planning the preprocedure care for this client, which nursing action is necessary?

Ask the client about allergies and previous reactions.

A client is experiencing anxiety about being hospitalized. What therapeutic communication techniques would the nurse use while interacting with the client? Select all that apply.

Ask the client to identify how they feel. Help the client identify the cause of the anxiety. Observe for expressions of helplessness and hopelessness.

The nurse has a prescription to collect a 24-hour urine specimen from a client. The nurse is demonstrating correct procedure when which technique is performed?

Ask the client to save a sample voided at the end of the collection time.

The nurse is caring for an 8-month-old infant. A urinalysis has been prescribed, and the nurse plans to collect the specimen. Which method would be used for urine collection in an infant?

Attaching a urine collection device to the infant's perineum

A clinic nurse is providing instructions to a client who is scheduled for a glucose tolerance test. Which instruction would the nurse provide to the client in preparation for the test?

Avoid alcohol, coffee, and tea for 36 hours before and during the test.

The nurse provides discharge instructions to a client suspected of having an intervertebral disc problem following myelography. Which instructions would the nurse provide? Select all that apply.

Avoid bending over. Avoid strenuous exercise. Rest with the head elevated.

The nurse is providing instructions to a client who is scheduled for a hepatobiliary scintigraphy (HIDA) scan. What would the nurse instruct the client to do?

Avoid oral intake except for water on the day of the procedure.

The nurse is scheduling diagnostic tests for a client. Which of the diagnostic tests prescribed would be performed last?

Barium swallow

The nurse is preparing to care for a client with coronary artery disease who has returned to the nursing unit following cardiac catheterization performed through the femoral vessel. The nurse checks the primary health care provider's (PHCP's) prescription and plans to allow which client position or activity following the procedure?

Bed rest with head elevation no greater than 30 degrees

A clinic nurse is providing instructions to a client regarding the procedure for collecting a midstream (clean-catch) urine specimen. What would the nurse instruct the client to do?

Begin the flow of urine and then collect the specimen.

The nurse is caring for a client with diabetic ketoacidosis whose respirations are abnormally deep, regular, and increased in rate. The nurse monitors the client, expecting that which occurs with this type of respiration? Select all that apply.

Blowing off carbon dioxide Correction of metabolic acidosis Correction of an acid-base imbalance Respiratory compensation

The nurse is caring for a client with metabolic alkalosis. The nurse plans care, knowing that most problems of metabolic alkalosis are related to increased stimulation of what systems? Select all that apply.

Cardiac Nervous Neuromuscular

The nurse is assessing a client with chronic obstructive pulmonary disease. With a finger sensor, the nurse measures the client's oxygen saturation with a pulse oximeter machine and obtains a reading of 78% while the client is on oxygen via nasal cannula at 2 L/min. The client is showing no signs of restlessness or dyspnea. What is the first nursing action?

Check the finger sensor's position and repeat the test.

The nurse is preparing to care for a client following a gastroscopy procedure. Which priority component would the nurse include in the nursing care plan?

Check the gag reflex by using a tongue depressor to stroke the back of the client's throat.

A client suspected of having lung cancer is to undergo pleural biopsy at the bedside. When planning for any potential complications of the procedure, the nurse would have which item(s) available at the bedside?

Chest tube and drainage system

A child is hospitalized because of persistent vomiting. The nurse would monitor the child closely for which priority problem?

Metabolic alkalosis

A client reports ingesting large amounts of oral antacids on a daily basis because of a gastric ulcer. The nurse plans care, knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance?

Metabolic alkalosis

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?

Metabolic alkalosis

The nurse provides information to a client with osteoporosis scheduled for a dual x-ray absorptiometry (DEXA) test. Which information would the nurse provide to the client? Select all that apply.

Metallic objects such as jewelry or belt buckles may interfere with the test and need to be removed. it is a painless test

The nurse is assisting the primary health care provider during a colonoscopy procedure. The nurse helps the client to assume which best position for the procedure?

Modified left lateral

The nurse is teaching a client about an upcoming colonoscopy procedure. The nurse would include in the instructions the fact that the client will be placed in which position for the procedure?

Modified left lateral

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply.

Nausea Confusion Tachycardia Light-headedness

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply.

Nausea Confusion tachycardia light headedness

The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child who is at low risk for contracting tuberculosis. The results indicate an area of induration measuring 10 mm. How would the nurse interpret these results?

Negative

The nurse is developing a plan of care for a client who is scheduled to return to the nursing unit after a liver biopsy. What is the appropriate position for the client?

On the right side

The nurse is caring for a client with respiratory failure related to Guillain-Barré syndrome. The nurse understands that what other extrapulmonary causes can lead to respiratory failure? Select all that apply.

Opioid analgesics, sedatives, anesthetics sleep apnea stroke

A client who does not speak English arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take?

Page an interpreter from the hospital's interpreter services.

The nurse is caring for a client who has undergone renal angiography using the left femoral artery for access. The nurse determines that the client is experiencing a complication of the procedure if which finding is observed?

Pallor and coolness of the left leg

The nurse is planning care for a client returning to the nursing unit after a bone biopsy done in the right leg. Which nursing action would be contraindicated in the postprocedure care for this client?

Place the right leg in a dependent position for 24 hours.

The nurse is preparing for the admission of a client with a suspected diagnosis of herpes simplex encephalitis. The nurse anticipates that which diagnostic test will be prescribed to confirm this diagnosis?

Polymerase chain reaction

A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse would plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis?

Potassium

The nurse explaining the procedure of indium imaging to a client with a bone infection would plan to include which information?

Some of the client's white blood cells are tagged with indium, which will later accumulate in infected bone.

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?

Potassium level of 3.0 mEq/L (3.0 mmol/L)

The nurse is caring for a client with chronic kidney disease. Arterial blood gas results indicate a pH of 7.30 (7.30), a Paco2 of 32 mm Hg (32 mm Hg), and a bicarbonate concentration of 20 mEq/L (20 mmol/L). Which laboratory value would the nurse expect to note?

Potassium level of 5.2 mEq/L (5.2 mmol/L)

The ambulatory care nurse is preparing a client who is scheduled for a liver biopsy. The nurse reviews the client's record and expects to note which laboratory results documented in the client's chart?

Prothrombin time

An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse would take which action to help the client experiencing this acid-base disorder?

Provide emotional support and reassurance.

A client is scheduled for a fiberoptic gastrointestinal procedure. The nurse instructs the client to remain on clear liquids the day before the test because a clear liquid diet supports which action?

Providing little or no residue

A client with acquired immunodeficiency syndrome is suspected of having cutaneous Kaposi's sarcoma. The nurse would prepare the client for which test to confirm the presence of this type of sarcoma?

Punch biopsy of the cutaneous lesions

A magnetic resonance imaging (MRI) study is prescribed for a client with a suspected brain tumor. Which priority action would the nurse include in the client's plan of care to ensure safety?

Remove all metal-containing objects from the client.

A client with coronavirus-2019 (COVID-19) has a prescription for a set of arterial blood gas (ABG) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse would take which action?

Remove the nasal cannula for 15 minutes; then have the ABG samples drawn.

A client is about to undergo a lumbar puncture (LP). The nurse understands that which is primarily involved in this test?

Removing a sample of cerebrospinal fluid for testing

The nurse is caring for a client who has been diagnosed as having an acute kidney injury (AKI) due to intrarenal causes. The nurse plans for which diagnostic test that is most effective in confirming this diagnosis?

Renal biopsy

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply.

Respirations that are abnormally deep Respirations that are increased in rate

The nurse is admitting to the hospital a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe, the client will be at risk for which acid-base imbalance?

Respiratory acidosis

The nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31, Paco2 is 50 mm Hg, and the bicarbonate (HCO3) level is 26 mEq/L. The nurse concludes that which acid-base disturbance is present in this client?

Respiratory acidosis

The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance?

Respiratory acidosis

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance?

Respiratory acidosis from inadequate ventilation

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg, and HCO3- is 22 mEq/L. The nurse interprets the results as indicating which condition?

Respiratory acidosis without compensation

A client who is found unresponsive has arterial blood gases drawn, and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg, and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition?

Respiratory acidosis without compensation

The nurse reviews a client's arterial blood gas results and notes that the pH is 7.30 (7.30), the Paco2 is 52 mm Hg (50 mm Hg), and the HCO3 is 22 mEq/L (22 mmol/L). The nurse interprets these results as indicating which condition?

Respiratory acidosis, uncompensated

Arterial blood gas analysis yields the following results: pH 7.48 (7.48), Paco2 32 mm Hg (32 mm Hg), Pao2 94 mm Hg (94 mm Hg), HCO3 level 24 mEq/L (24 mmol/L) for a client seen in the health care clinic. The nurse interprets that the client has which acid-base disturbance?

Respiratory alkalosis

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mm Hg), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?

Respiratory alkalosis, compensated

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg, and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?

Respiratory alkalosis, compensated

The nurse reviews a client's arterial blood gas values and notes a pH of 7.50 (7.50), a Paco2 of 30 mm Hg (30 mm Hg), and an HCO3 of 25 mEq/L (25 mmol/L). The nurse would interpret these values as an indication of which condition?

Respiratory alkalosis, uncompensated

The nurse would use this specimen collection container to collect which type of specimen? Refer to figure.

Respiratory secretions

The nurse reviews the primary health care provider's (PHCP's) prescriptions for a child with a streptococcal infection. The PHCP prescribes an antistreptolysin O titer. Based on this prescription, which diagnosis would the nurse suspect in the child?

Rheumatic fever (RF)

A sweat test is performed on an infant with a suspected diagnosis of cystic fibrosis (CF). The nurse reviews the results of the test and notes that the chloride level is 40 mEq/L (40 mmol/L). How would the nurse interpret this finding?

Suggestive of CF

How would the nurse position the client for pericardiocentesis to treat cardiac tamponade?

Supine with the head of the bed elevated at a 45- to 60-degree angle

The ambulatory care nurse is preparing to assist the primary health care provider in performing a liver biopsy on a client. The client is receiving a local anesthetic for the procedure. The nurse would assist the client into which position for this test to be performed?

Supine with the right hand under the head

A client has just returned from the cardiac catheterization laboratory. The left-sided femoral vessel was used as the access site. How would the nurse position the client?

Supine, with the head of the bed elevated about 15 to 30 degrees

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas (ABG) values are pH = 7.53, Pao2 = 72 mm Hg, Paco2 = 32 mm Hg, and HCO3- = 28 mEq/L (28 mmol/L). Which conclusion about the client would the nurse make?

The client is probably hyperventilating.

The nurse is caring for a hospitalized client with chronic obstructive pulmonary disease who is retaining carbon dioxide (CO2). The nurse anticipates which physical response will initially occur?

The client's arterial blood gas results will reflect acidosis.

A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. How would the nurse describe this test to the client?

The dye injected may cause a warm, flushing sensation.

The nurse is preparing to provide preoperative teaching to a non-English-speaking client and the client's family. Which nursing action would be most effective for teaching the client?

The nurse secures the assistance of a professional interpreter to communicate with the client.

The nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse plans interventions, knowing that as the client's CO2 level rises, what will occur with the blood pH?

The pH will fall

The nurse is teaching a client about what to expect during a gallium scan. The nurse would include which item as part of the instructions?

The procedure takes about 30 to 60 minutes to perform.

A client is scheduled for a Papanicolaou (Pap) smear at the next scheduled clinic visit. The nurse provides instructions to the client regarding preparation for this test. Which statement would the nurse plan to include in the teaching?

The test is painless.

The charge nurse is assessing the nurse's knowledge about the use of an interpreter. Which statement made by the nurse requires a need for further teaching?

The use of an interpreter does not need to occur until the client requests one

The nurse is explaining a preoperative teaching plan to an English-speaking client. What are some other aspects of verbal communication the nurse would employ? Select all that apply.

Timing Volume Voice tone ability to share thoughts and feelings

A client is about to undergo a lumbar puncture (LP). The nurse prepares to place the client in a side-lying position, with legs pulled up and head bent down onto the chest for which purpose?

To open the spaces between the vertebrae

A client with suspected gallbladder disease is scheduled for an oral cholecystogram. The nurse asks the dietary department to bring low-fat foods for the evening meal for which purpose?

To prevent contraction of the gallbladder before testing

The nurse is providing instructions for a client who will collect a stool specimen for an occult blood test. The nurse instructs the client that it is best to avoid which food for 3 days before collection of the stool specimen?

Turnips

A client is scheduled for a test to detect kidney tumors or cysts. What test is considered safest for the client?

Ultrasonography

A primary health care provider is about to perform a paracentesis for a client with cirrhosis and abdominal ascites. The nurse assisting with the procedure would help the client into which position?

Upright

A client recovering from cardiac surgery has a left pleural effusion and is about to undergo a thoracentesis. What position would the nurse place the client in for the procedure?

Upright and leaning forward with the arms on an over-the-bed table

The nurse is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. The nurse plans to implement which intervention to obtain the specimen?

Use a sterile plastic container for obtaining the specimen.

A client with diabetes mellitus is scheduled for a fasting blood glucose level determination in the morning. The nurse tells the client not to eat or drink after midnight. When the client asks for further information about fluid and food intake, the nurse clarifies by stating that which would be acceptable to consume before the test?

Water

A stool for culture needs to be obtained from a client suspected of having Clostridium difficile infection. What steps would the nurse plan to implement when obtaining the specimen? Select all that apply.

Wearing sterile gloves Using a sterile container Sending the specimen directly to the laboratory

A client returns to the nursing unit after undergoing an esophagogastroduodenoscopy (EGD). Which is the appropriate nursing intervention?

Withhold oral fluids until the client's gag reflex has returned.

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings?

pH 7.25, Paco2 50 mm Hg

The nurse is caring for a client whose arterial blood gas results reveal alkalosis. What client reactions would the nurse expect to see? Select all that apply.

tetany tingling Numbness Restlessness