Diagnostic Test Flashcards
A nurse is preparing a client scheduled for a right mastectomy. Which statement indicates the need for further assistance?
- The client refuses to sign a blood consent since she is a Jehovah witness
- The client identifies the right breast as the surgical site for a right mastectomy
- The client signed the consent with an x, which is witnessed by two licensed personnel.
- The client expresses doubt over her decision and asks the nurse to explain more about the procedure.
Number 4 is correct.
Expressing doubt and asking further questions about the procedure to the nurse indicates that the client may not be fully informed and should confer further with the health care provider. The nurse may clarify facts, but it is the health care provider’s responsibility to give detailed information about a surgical procedure. The nurse is responsible for ensuring the client has been adequately informed. A client may refuse to sign a blood consent due to religious beliefs prior to surgery. The client has correctly identified the surgical site, which is to be expected. The client who cannot write may sign with an x as long as it is witnessed by two people.
The nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which client task should the nurse delegate to the UAP?
- a client whose IV infiltrated and needs replacing
- a client on BiPAP who needs arterial blood gases (ABGs) drawn
- a client with mild dementia who needs assistance with her food tray
- a client who needs a wet to dry dressing change on an abdominal incision
Number 3 is correct.
Assessing the IV site and inserting an IV is beyond the scope of practice for a UAP and should be performed only by the licensed nurse. Drawing ABGs should be performed by licensed nurse or respiratory therapist per facility policy. Assisting a client with a meal tray is within the scope of practice for a UAP. Dressing changes should be performed by the licensed nurse. UAPs may not provide direct nursing care or perform nursing interventions requiring specialized nursing, knowledge, judgement, or skill.
An external weather disaster has flooded the emergency department with several new clients. Which client should the nurse see first?
- The client complaining of chest pain and nausea who is diaphoretic
- The client with a simple fracture of the radius from a fall on a staircase
- The client complaining of slight redness and itching at the IV site in his hand
- The client presented with a sprained ankle from a tree branch falling on him
Number 1 is correct
Triage works on the principle that clients with the highest acuity have priority ove clients with injuries or conditions that are not considered life-threatening. Chest pain, nausea and diaphoresis indicate a possible myocardial infarction, which can be life- threatening and requires immediate intervention. Fractured and sprains are non-urgent and can wait for treatment. Redness and itching at an IV site indicates a need to asses the site and remove and replace the IV, but is not immediately life- threatening.
A nurse is working with an unlicensed assistive personnel (UAP) to perform a bed bath on a client. The nurse notes the smell of alcohol on the UAPs breath. Which is a priority nursing action?
- Work closely with the UAP during the shift and observe for any signs of impairment
- Complete the bed bath without comment. The unit already short one staff member.
- Offer chewing gum to the UAP. Since she does not give medications, she can do her job as she does not appear impaired.
- Call for another nurse to complete the bath and immediately report the UAPs to the charge nurse or unit manager.
Number 4 is correct
The professional nurse works under the framework of six ethical principles. Nonmaleficence emphasizes protecting the client from harm. Client safety is always a priority. Another nurse may step in and complete the bath, ensuring that the client is not left alone with impaired personnel. Options 1, 2, and 3 allow the impaired UAP to remain on duty, possibly causing harm to the client. The nurse also has an ethical and legal duty to report situations that may cause client danger. Failure to do so may result in disciplinary action by the board of nursing for the nurse involved, regardless of whether harm comes to the client.
The nurse has received report on the assigned night-shift clients. Which client should the nurse see first.
- A mildly confused client due for a dressing change on a diabetic ulcer to the heel.
- An elderly, stable client who just returned from an MRI to rule out kidney mass
- A client whose IV pump has started beeping, indicating that the antibiotic has completed infusing
- A client complaining of sudden warmth and pain on an appendectomy incision site 48hours after surgery
Number 4 is correct
Classic signs of localized infection include sudden warmth, redness, pain at the site and swelling caused by the inflammatory process. This client should be assessed first due to the risk of infection following surgical procedures. The health care provider should be notified immediately so that lab work can be ordered and appropriate course of treatment started. The client needing a dressing change is not as urgent as a client with infection. A stable client returning from MRI is not the priority. The client with an IV pump beeping can be seen once health care provider has been notified. The risk of infection and subsequent complications take priority over a beeping IV pump.
The nurse is working triage in the ED when four clients present at the same time. Which client should be seen first?
- A 45- year-old female on oral contraceptives with unusual heavy menstrual bleeding
- A 24-year- old with a dog bite to the leg from the family dog who is current on rabies shots
- An irritable 4- month-old with a petechial rash, nuchal rigidity, and temperature of 103.4^F
- A 16-year- old football player with a twisted ankle who has no deformity and a pedal pulse
Number 3 is correct
Petechial rash, nuchal rigidity, and fever are signs of meningitis, which is a medical emergency, especially in an infant. The client with heavy menstrual bleeding is not as urgent as the infant. Dog bites from a known pet current on rabies shots are less urgent than bites from a dog with an unknown rabies status. A twisted ankle with a pedal pulse and no deformity is not life threatening and can be seen after more urgent clients.
The nurse is caring for clients on a medical-surgical floor. Which tasks related to pain management can be delegated to unlicensed assistive personnel (UAP)? Select all that apply
- Assessing the pain level on a scale of 1-10
- Reminding clients to report pain immediately
- Reporting facial grimacing in unresponsive clients
- Asking clients directly, “Are you having any pain right now?”
- Giving acetaminophen (Tylenol) after the nurse obtains the medication but is interrupted to attend a code blue before she administers it
Numbers 2, 3, and 4 are correct
Asking clients if they currently have any pain and reminding clients to report pain are within the scope of practice for the UAP. The UAP may also report facial grimacing to the nurse, as assessment is a nursing action. No medications, even over the counter ones, may be given by anyone other than the licensed nurse. If the nurse is interrupted for an emergency, another nurse may administer the medication after assessing the client’s pain and checking the chart for any allergies, if facility protocols permit this. The nurse is ultimately responsible for the task that has been delegated.
A newly graduated nurse is working with a pediatric unit. Which client assignment is most appropriate for the nurse?
- A 2 year old with hemophilia A who has suddenly become less responsive
- A 15 year old with sickle cell disease complaining of lower right quadrant abdominal pain
- A 6 year old who just had a tonsillectomy 2 hours earlier and is frequently swallowing
- A 12year old with newly diagnosed type 2 diabetes whose parents need teaching on insulin
Number 2 is correct
Clients with sickle cell disease commonly present with pain during a crisis. The newly graduated nurse is qualified to assess the clients pain and administer ordered pain medications. A client with a clotting disorder and a decreased level of consciousness is an emergency situation due to possible intracerebral bleeding and is not appropriate for an inexperienced nurse. Swallowing after a tonsillectomy indicates possible bleeding and should be assessed by a more experienced nurse. Client teaching is an important and more advanced skill that takes time to develop. Insulin is a high-alert drug, and incorrect information from the new nurse may cause harm to the client.
The nurse is preparing to transfer a client from the ICU to the floor. Which of the following ensures continuity of care for the client? Select all that apply.
- Using approved abbreviations in documenting care
- Providing report on the client using standard hand of reports
- Informing the receiving nurse of any pending lab results and when they are expected
- Informing the receiving nurse of any care that needs to be done, such as bathing
- Telling the receiving nurse that the family is demanding and asks to many questions
Numbers 1, 2, 3, and 4 are correct
Ensuring continuity of care is especially important when the client is being transferred to another area of the hospital. Options 1, 2, 3, and 4 are guidelines that ensure continuity of care. Addressing pending lab results, listing client requests that the nurse was unable to do, and informing the receiving nurse of upcoming medications or glucose checks that will need to be done shortly after the client arrives make it easier for the receiving nurse to be sure that upcoming tests or medications are not missed. Complaining about the family is unprofessional and takes the focus away from client needs. A smooth transition is essential to ensure that no orders are overlooked. The nurse should be prepared to answer questions from the receiving nurse if needed for clarification after the client is transferred.
A client has been admitted to the oncology unit and has a large amount of cash, several credit cards, and several pieces of expensive-looking gold jewelry in her possession. Which action is the most appropriate?
- Tell the client to hide everything in her purse or bag and put it in the closet.
- Offer to take her belongings to the charge nurse’s office where they can be locked up
- Suggest that the client put her valuables in a sock and place it in the bottom of the bedside table under some clothing
- Inform the client the hospital policy regarding valuables and suggest that she give them to a trusted family member or to security for safe keeping
Number 4 is correct
Most hospitals provide security to lock up client’s valuables, along with a receipt or form for identification for claiming the items. All items placed in security must be documented on the admission form and signed. The facility is not responsible for valuables left in the room by the clients, and the nurse should be sure that the client is aware of this policy and understands it. Options 1 and 3 still leave the valuables subject to theft. Locking them up in the charge nurses office is not an appropriate option, as this places charge nurse in a position of responsibility. Many hospitals admissions are unplanned, and the best advice the nurse can give a new client is to send home anything of value.
The nurse is caring for a 7year old child who presents to the ED with multiple bruises, a fractured ankle, and cigarette burns on the arms. Which action by the nurse is most appropriate?
- Ask the parents if they burned the child with cigarettes
- Ask the client to tell you what happened to cause bruising and burns
- Inform the parents that they cannot leave with the child until they talk to the police
- Notify the charge nurse immediately so that the suspected child abuse can be reported
Number 4 is correct
Any suspected cases of abuse and neglect must, by law, be reported to the authorities. The ED will have policies and procedures to guide staff on appropriate responses to suspected child abuse cases. Option 1 assumes that the parents are responsible for the burns and may provoke a violent response. While it is appropriate to ask the client what happened, the nurse should be aware that many abused children are coached to say that they fell off a swing or had another type accident when asked about their injuries by authority figures. Option 3 is both presumptive and accusatory. Additionally, it may also provoke a violent response. Child abuse cases require collaboration among nurses, physicians, social workers, police and family services. The nurse should remain alert to verbal or nonverbal cues that the situation may intensify, and follow facility guidelines.
Which precaution must a nurse take when checking the blood pressure of an HIV positive client?
- Wear gloves
- Wear gown
- Use contract precautions
- Wash hands
Number 4 is correct
Washing hands is sufficient since taking a client’s blood pressure does not involve contact with blood or secretions. The other listed precautions would be appropriate if blood or secretions is involved.
The pediatric nurse is preparing a child acute lymphocytic leukemia for discharge. The discharge plan should include all but which of the following statements?
- Restrict naps to allow more complete rest at night
- Increase intake of protein, iron, and vitamin C to provide nutrients required for hemoglobin production
- Keep a food diary to evaluate dietary intake
- Restrict antacids, tetracyclines and phosphorus salt
Number 1 is correct
Arranging rest periods throughout the day helps promote the client’s ability to participate in an array of desired activities. Increasing intake of protein, iron and vitamin C aids in hemoglobin production. Keeping a food diary helps document actual nutritional intake. Restricting antacids, tetracyclines, and phosphorus salts will avert absorption of iron.
The nurse teaches a group of fire fighters about the spread of tuberculosis (TB). Which statement by the fire fighter indicates the teachings has been effective?
- I could get TB if I come in contact with blood from an infected person
- I can share a cup of coffee with someone who is infected with TB
- I could get TB if I inhale infected droplets when an infected individual coughs
- I need to refrain from shaking hands with an infected person
Number 3 is correct
TB bacteria is spread through the air from one person to another. When a person breathes in TB bacteria, the bacteria can settle in the lungs and begin to grow. TB is not transmitted through blood, sharing a cup of coffee, or shaking hands with an infected person.
After administering the annual Mantoux tuberculin skin test to employees, the nurse instructs the staff to return within how many hours after administration to have the results determined?
- 12 to 24 hours
- 24 to 48 hours
- 48 to 72 hours
- 72 to 84 hours
Number 3 is correct
The Center for Disease Control recommends the skin test be read 48-72 hours after administration. A test is considered positive if an induration of 5-15 millimeters is observed at the injection site. Results read after 72 hours are not accurate and another skin test needs to be conducted.
A client is diagnosed with Meniere’s disease. Which nursing diagnosis would take priority dor the client?
- risk of injury
- disturbed body image
- low self-stem
- Impaired skin integrity
Number 1 is correct
Menieres disease occurs when the pressure of the fluid in part of the inner ear gets to high. As a result, the client is at risk for injury related to altered mobility because of gait disturbance and vertigo. While hearing loss may occur, this does not result in disturbed body image, low self-esteem, or impaired skin integrity.
While driving, the client forgets how to get home. Which lobe could be dysfunctional?
- Temporal
- Parietal
- Occipital
- Frontal
Number 4 is correct
The frontal lobe regulates intellectual functions, such as complex problem solving. The temporal lobe regulates memory, speech and comprehension. The parietal lobe regulates reading ability, writing ability, and spatial relationships. The occipital lobe is responsible for vision function.
At the scene of an accident, which intervention applies to a client with a suspected neck injury?
- Administer CPR
- Keep the person warm
- Do not move the client
- Ask the client to state her name and birthday
Number 3 is correct
Do not move a client whose neck is in an awkward position or who is unconscious. Instead, keep the client immobilized and get help immediately. In this situation, CPR is not needed for the client. Keeping the client warm is necessary but not a priority. Asking the client to state her name and birthday may be appropriate if a brain injury is suspected, not a neck injury.
Which treatment should be included in the immediate management of acute appendicitis?
- Prevent fluid volume deficit
- Administer antibiotic therapy
- Reduce anxiety
- Relieve pain
Number 4 is correct
Relieving pain is the most immediate need for management. Preventing fluid volume deficit by infusion of IV fluids should occur once the client has experienced initial control of pain. Administration of antibiotic therapy will be important during the recovery phase. Reducing anxiety is important and will be partially addressed with the reduction of pain.
Medical management of a client with acute diverticulitis should include which treatment?
- Increased fiber in diet
- Administration of antibiotics
- Pain medication administration
- Liquid diet for 1-2 days
Number 2 is correct
Acute diverticulitis results from inflammation of the diverticula, typically from an infection. As such, the priority treatment is administration of antibiotics to address the root cause of the condition. Gradually increasing fiber in the diet will occur during the recovery stage of the disease. Pain medication for residual pain would be a second management approach after initiation of antibiotic protocol. To promote rest of the intestinal tract, a liquid diet is advisable for an undeterminable time.
An enema is prescribed for a client with suspected appendicitis. The nurse should take which action?
- Tell the client to lie on his left side
- Explain the procedure to the client
- Compile necessary equipment
- Question the physician about the order
Number 4 is correct
An enema is contraindicated for a client with suspected appendicitis as increased intestinal motility may aggravate the suspected appendicitis. When enema administration appropriate, the other answers are correct.
A 28 year old client has just given birth. At one minute the baby appears healthy, with the exception of bluish hands. Which of the following would the nurse midwife pronounce?
- The Apgar score is 11
- The Apgar score is 9
- The Apgar score is 6
- The Apgar score is 4
Number 2 is correct
Apgar scoring consists of 5 areas (muscle tone, heart rate, reflex response, color, breathing) with a possible score of 0, 1, or 2 for each area. An Apgar of 9 is correct: four of the five categories for this example rate a score of 2 (subtotal of 8) with 1 point for good color with bluish hands (or feet). The maximum score achievable is 10. A score of 4 or 6 will require support, typically in breathing.
The clients first day of her last period was January 24. Which of the following should the nurse tell the client is her expected delivery?
- September 30
- October 31
- November 15
- December 1
Number 2 is correct
Due date is determined by adding 9 months and 7 days to the clients last menstrual cycle, making October 31 the correct day. September 30 is one month to early. November 15 and December 1 would make the baby overdue.
The nurse is discussing concerns the parents has with his 3 year old. The parental identifies limitations in the child’s activities. Select all that should be of concern to the nurse
- Unable to work simple toys
- Unable to understand simple instructions
- Unable to say first and last name
- Unable to name any colors or numbers
Numbers 1 and 2 are correct
By the age of 3 the child should be able to work simple toys and understand simple instructions. In contrast, the ability to say the first and last name and to name colors and numbers are milestones that occur at 4 years old.
The nurse is providing education at a senior center. Which of the following measures will the nurse say is most effective in attaining normal blood pressure in a client with hypertension?
- Eating red meat daily
- Increasing potassium and calcium intake
- increasing fluid intake
- Decreasing sodium intake
Number 4 is correct
Decreasing sodium intake is an effective way to reduce blood pressure in a client with hypertension. Eating red meat daily, increasing potassium and calcium intake, and increasing fluid intake are not measures that affect blood pressure readings.
A 9 month old child is registered to attend a local childcare clinic. Upon inicial intake, the nurse discovers the child had received the first and second dose of hepatitis B vaccine. What is the best course of action for the nurse to recommend to the parents?
- No action; a third dose of the vaccine is not recommended
- Immediately inoculate the child given the high risk of not having a third vaccine
- Wait until the child is 12 months to give the vaccine
- Schedule the child for the third vaccine at the earliest convenience
Number 4 is correct
The nurse should recommend the child receive the third vaccine at the earliest convenience as it should be routinely administered anytime from 6 to 19 months of age. Thereafter, the third dose may be safely administered through the age of 18 years old. A third dose of the hepatitis B vaccine is advisable. The child is not in immediate danger by not having had the third vaccine.
The nurse is teaching a smoking cessation program. He will state that which of the following benefits of quitting appear within one year?
- Risk of coronary heart disease is the same as that of a nonsmoker
- Carbon monoxide level in blood drops to normal
- Risk of dying from lung cancer is about half that of a smoker
- Risk of having a stroke is reduced to that of a nonsmoker
Number 2 is correct
Within 12 months after quitting, the carbon monoxide level in a smokers blood drops to normal. At 15 years after quitting, the risk of coronary heart disease is the same as that of a nonsmoker. At 10 years after quitting, the risk of dying of lung cancer is about half that of a smoker’s. At 5 to 15 years after quitting, the risk of having a stroke is reduced to that of a nonsmoker’s.
The nurse is preparing a community educational presentation. The topic is the leading causes of death for people ages 12-19. The nurse knows that which of the following should be presented?
- Unintentional injuries
- Cancer
- Homicide
- Suicide
Number 1 is correct
According to the Center for Disease Control and Prevention, accidents (unintentional injuries) account for nearly one half of all teenage deaths. The other four leading causes of death among teenagers are homicide, suicide, cancer and heart disease.
The nurse identifies a client’s learning preferences as visual. Which of the following would be appropriate when teaching the client about insulin injection?
- An audiotape
- An orange, an insulin syringe an alcohol wipe, and a bottle of sterile saline
- Classroom discussion
- Instructional pamphlet
Number 4 is correct
The instructional pamphlet is visual, allowing the client to see words and pictures, which is appropriate given the client’s preference. The audiotape and classroom discussion are auditory, allowing the client to hear words. The orange/ syringe/ alcohol wipe/ bottle are tactile, allowing the client to touch.
The nurse is caring for a client with en stage kidney disease and multiple organ failure. Which action by the nurse indicates an understanding of end of life care? Select all that apply.
- The nurse explains signs and symptoms that indicate death is near.
- The nurse explains to the client and family what to expect during the final phase of the illness
- Cultural beliefs are acknowledged, but priority is placed on life-lengthening treatment options.
- The nurse avoids talking to the client about impending death to avoid upsetting him and the family
- The nurse asks the client and family what their goals and wishes are regarding care, pain management, and emergency resuscitation.
N
The nurse is talking in the lounge with other nurses about grief and loss. The nurse understands which to be true regarding grief and loss. Select all that apply.
- The process of grief is detrimental to physical and emotional health
- Age, gender, and culture are a few factors that influence the grieving process
- The nurse must explore his own feelings about death before he may effectively help others
- The nurse should discourage expression of grief and loss because it may upset other clients nearby
- The nurse can help the family develop ways to relieve loneliness and depression following the death of a loved one
N
The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?
- A client in a halo vest following an automobile accident
- A child with severe autism who is having a tonsillectomy
- A teenager who broke her leg during cheerleader practice
- A schoolteacher who was hospitalized for shortness of breath
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