Chapter 34 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/E
Chapter 34

Question 1

Type: MCSA

Which role would the nurse perform in the intratest phase?

1. Assess the data.

2. Collect the specimen.

3. Observe the client.

4. Prepare the client.

Correct Answer: 2

Rationale 1: Assessing the data occurs in the pretest phase.

Rationale 2: Collecting the specimen comes during the intratest phase.

Rationale 3: Observing the client occurs in the post-test phase as follow-up after the testing.

Rationale 4: Preparing the client occurs in the pretest phase.

Global Rationale: Page Reference: 808

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts:

Learning Outcome: 01 Describe the nurses role for each of the phases involved in diagnostic testing.

Question 2

Type: MCSA

The nurse will instruct a client about a blood test specific for heart failure which is:

1. BNP

2. CBC

3. LDH

4. PKU

Correct Answer: 1

Rationale 1: The specific blood test to detect and guide treatment for heart failure is the BNP test. B-type natriuretic peptide is secreted primarily by the left ventricle in response to increased ventricular volume and pressure.

Rationale 2: A CBC is a complete blood count which includes hemoglobin and hematocrit measurements, erythrocyte (red blood cells) count, leukocyte (white blood cell) count, red blood cell indices, and a differential white cell count.

Rationale 3: This test measures the amount of the enzyme lactic dehydrogenase in the body.

Rationale 4: This is a test to assess for phenylketonuria in the newborn.

Global Rationale: Page Reference: 809

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 02 List common blood tests.

Question 3

Type: MCSA

Which diagnostic study will determine how well blood glucose levels have been controlled in a client?

1. Blood chemistry

2. Capillary blood glucose

3. Hemoglobin A1c

4. Serum electrolytes

Correct Answer: 3

Rationale 1: A blood chemistry is a number of tests performed on blood serum. It can include LDH, CK, AST.

Rationale 2: The capillary blood glucose is used to determine or monitor blood glucose levels of clients at one point in time but not over time.

Rationale 3: The glycosylated hemoglobin or hemoglobin A1c (HbA1c) is a measurement of blood glucose that is bound to hemoglobin. Hemoglobin A1c is a reflection of how well blood glucose levels have been controlled.

Rationale 4: Serum electrolytes are often routinely ordered for any client admitted to a hospital as a screening test for electrolyte and acidbase imbalances. The most commonly ordered serum tests are for sodium, potassium, chloride, and bicarbonate ions.

Global Rationale: Page Reference: 812

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 02 List common blood tests.

Question 4

Type: MCSA

Which returned demonstration by the client indicates an accurate understanding of performing a blood glucose monitoring test?

1. The client punctures the fingertip.

2. The client puts on gloves.

3. The client smears the blood on the reagent strip.

4. The client washes the hands.

Correct Answer: 4

Rationale 1: Once the appropriate site is selected for puncture, the side of the finger is used where there are fewer nerve endings.

Rationale 2: Since the client is performing self-blood glucose monitoring, applying gloves is not necessary.

Rationale 3: Then once the specimen is obtained, one holds the reagent strip under the puncture site until enough blood covers the indicator square. It is not smeared on the pad, which would cause an inaccurate reading.

Rationale 4: One of the first steps the client would perform is hand washing for infection control.

Global Rationale: Page Reference: 815

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 11 Verbalize the steps used in:
a. Obtaining a capillary blood specimen to measure blood glucose.

Question 5

Type: MCSA

A client asks the nurse, Why do I have to monitor my blood glucose levels? An appropriate response from the nurse would be:

1. Because your doctor ordered it.

2. If I were you, I would monitor the blood glucose when I didnt feel good.

3. Monitoring your blood glucose better enables you to manage your diabetes.

4. You can eat anything you want.

Correct Answer: 3

Rationale 1: Because your doctor ordered it is not a good enough reason.

Rationale 2: The nurse should never tell a client what he or she would do; that is only an opinion.

Rationale 3: Blood glucose monitoring improves diabetes management. By testing ones blood, one can change the insulin regimen to maintain a normal glycemic range.

Rationale 4: Eating anything the client wants would give rise to too many episodes of hyperglycemia and make the diabetes harder to control.

Global Rationale: Page Reference: 815

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Explain the rationale for the collection of each type of specimen.

Question 6

Type: MCSA

What is the responsibility of the nurse when collecting a specimen from a client?

1. Always accompany the client to collect a specimen.

2. Handle the specimen discreetly.

3. Clean technique should be used with all specimen collection.

4. Use day-old specimens.

Correct Answer: 2

Rationale 1: The nurse should provide the client as much privacy as possible.

Rationale 2: The nurse should handle the specimen discreetly to avoid embarrassing the client.

Rationale 3: Aseptic technique is used to collect specimens to prevent contamination.

Rationale 4: Specimens should be transported promptly to the lab. Fresh specimens provide the most accurate results.

Global Rationale: Page Reference: 818-820

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Discuss the nursing responsibilities for specimen collection.

Question 7

Type: MCSA

A doctors order for a 24-hour stool specimen collection indicates to the nurse that the physician needs to:

1. Analyze the stool for dietary products and digestive secretions.

2. Detect the presence of bacteria or viruses.

3. Detect the presence of ova and parasites.

4. Determine the presence of occult blood.

Correct Answer: 1

Rationale 1: The nurse needs to collect and send the total quantity of stool expelled at one time instead of a small sample so that the specimen can be analyzed for dietary products and digestive secretions.

Rationale 2: To detect bacteria or viruses only a small amount of stool is needed.

Rationale 3: To detect ova or parasites only a small amount of stool is needed.

Rationale 4: To determine the presence of occult blood, only a small amount of stool is needed.

Global Rationale: Page Reference: 824

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 04 Explain the rationale for the collection of each type of specimen.

Question 8

Type: MCSA

A client is being treated for tuberculosis, and the doctor writes an order to collect a sputum specimen. What is the rationale behind this order?

1. For acid-fast bacillus

2. To assess the effectiveness of therapy

3. To identify origin, structure, function, and pathology of cells

4. To identify the specific organism

Correct Answer: 2

Rationale 1: It is already known that TB is acid-fast.

Rationale 2: The reason for this doctors order is to assess if the therapy ordered is effective for this client.

Rationale 3: TB does not require cytology for identification; therefore, there is no need for identifying origin, structure, and function.

Rationale 4: Knowing the client has tuberculosis, the organism has already been identified.

Global Rationale: Page Reference: 826

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 04 Explain the rationale for the collection of each type of specimen.

Question 9

Type: MCSA

Which of the following steps should the nurse perform when obtaining a sputum specimen?

1. Collect at least 30 mL of sputum.

2. Offer mouth care.

3. Take shallow breaths.

4. Wear a mask.

Correct Answer: 2

Rationale 1: At least 1 to 2 teaspoons or 4 to 10 mL should be collected

Rationale 2: Offer mouth care so that the specimen will not be contaminated with microorganisms from the mouth.

Rationale 3: The client should be instructed to breathe deeply and then cough, not take shallow breaths as this would not raise the sputum.

Rationale 4: A mask needs to be worn only if TB is suspected.

Global Rationale: Page Reference: 826-827

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 07 Describe how to collect sputum and throat specimens.

Question 10

Type: MCSA

Which instruction should the nurse give to the client when a stool specimen is to be collected?

1. Defecate in the toilet.

2. Follow sterile technique.

3. Send at least 60 mL of specimen.

4. Void before the specimen is collected.

Correct Answer: 4

Rationale 1: The client should defecate in a clean bedpan or bedside commode, not the toilet.

Rationale 2: Aseptic technique should be followed, not sterile, because the bowel contains microorganisms.

Rationale 3: The usual amount needed for a specimen is 15 to 30 mL, not 60 mL.

Rationale 4: To avoid contaminating the specimen, the client should void before the specimen is collected.

Global Rationale: Page Reference: 820

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 05 Describe how to collect and test stool specimens.

Question 11

Type: MCSA

Which of the following instructions should be given to the client for obtaining a clean voided urine specimen?

1. Collect at least 5 mL of urine.

2. Collect the first voided specimen in the morning.

3. Keep the specimen on ice.

4. Void in a sterile cup.

Correct Answer: 2

Rationale 1: At least 10 mL of urine is generally sufficient for a routine urinalysis.

Rationale 2: Routine urine examination is usually performed on the first voided specimen in the morning because it tends to have a higher, more uniform concentration and a more acidic pH than specimens later in the day.

Rationale 3: A timed urine specimen should be refrigerated or kept on ice to prevent bacterial growth or decomposition of urine components.

Rationale 4: A clean voided urine specimen does not need to be placed in a sterile container, but a clean-catch or midstream specimen does.

Global Rationale: Page Reference: 821

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Verbalize the steps used in:
b. Collecting a urine specimen for culture and sensitivity by clean catch.

Question 12

Type: MCSA

When collecting a sputum specimen, the nurse should have the client:

1. Apply sterile gloves.

2. Clear the throat.

3. Cough to bring up secretions.

4. Rinse the mouth with mouthwash prior to the collection.

Correct Answer: 3

Rationale 1: The client does not need to put on sterile gloves. The only thing that has to remain sterile is the inside of the collecting container.

Rationale 2: Clearing the throat will not help produce the sputum; the client has to cough.

Rationale 3: Clients need to cough to bring sputum up from the lungs, bronchi, and trachea into the mouth in order to expectorate the specimen into a collecting container.

Rationale 4: The client is allowed to use mouthwash after the collection but not before because the antiseptic could alter the results.

Global Rationale: Page Reference: 826

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 07 Describe how to collect sputum and throat specimens.

Question 13

Type: MCSA

What client response would indicate to the nurse that instruction about a throat culture has not been effective?

1. I need to hyperextend my neck.

2. I need to say ah.’

3. I will need to sit up.

4. The nurse will use a light.

Correct Answer: 1

Rationale 1: The client should extend the tongue when a throat culture is to be taken, not hyperextend the neck

Rationale 2: Saying ah is done when collecting a throat specimen.

Rationale 3: The client will need to sit up when having a throat culture done.

Rationale 4: The nurse will use a light when obtaining a throat culture.

Global Rationale: Page Reference: 827

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 07 Describe how to collect sputum and throat specimens.

Question 14

Type: MCSA

What is the nursing priority for a client who is to have a barium enema?

1. Assess bowel sounds.

2. Assess for allergies.

3. Cleanse the bowel.

4. Keep the client NPO.

Correct Answer: 3

Rationale 1: Assessing bowel sounds is important, but if the bowel is not free of feces, the barium enema will not be accurate.

Rationale 2: Assessing for allergies is important, but if the bowel is not free of feces, the barium enema will not be accurate.

Rationale 3: For visualization of the colon, the bowel has to be cleansed; otherwise the test cannot be performed. Therefore, that is the first priority the nurse must keep in mind.

Rationale 4: Keeping the client NPO is important, but if the bowel is not free of feces, the barium enema will not be accurate.

Global Rationale: Page Reference: 828

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 08 Describe visualization procedures that may be used for the client with gastrointestinal, urinary, and cardiopulmonary alterations.

Question 15

Type: MCSA

A client is to have an echocardiogram. Which statement by the client indicates the teaching about the test has been effective?

1. Im told this test causes no discomfort.

2. I will have to walk on a treadmill.

3. I will need to remain NPO.

4. I will need to take my pulse prior to the test.

Correct Answer: 1

Rationale 1: An echocardiogram causes no discomfort, although conductive gel is used and it may be cold.

Rationale 2: The client does not need to walk on a treadmill for this test.

Rationale 3: The client does not need to be NPO for this test.

Rationale 4: The client does not need to take his pulse before the test.

Global Rationale: Page Reference: 828

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 08 Describe visualization procedures that may be used for the client with gastrointestinal, urinary, and cardiopulmonary alterations.

Question 16

Type: MCSA

Which of the following replies from a client indicates that no further teaching is required regarding a cystoscopy?

1. During the procedure the physician will take x-rays.

2. I will be awake for this procedure.

3. The doctor will be able to see my kidneys.

4. The scope is a lighted instrument inserted through the urethra.

Correct Answer: 4

Rationale 1: Since it is direct visualization, x-rays are not needed nor taken.

Rationale 2: Clients are either put to sleep or consciously sedated during this procedure; they are not awake.

Rationale 3: Only the bladder, ureteral orifices, and urethra are directly visualized.

Rationale 4: The cystoscope is a lighted instrument inserted through the urethra.

Global Rationale: Page Reference: 828

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 08 Describe visualization procedures that may be used for the client with gastrointestinal, urinary, and cardiopulmonary alterations.

Question 17

Type: MCSA

What should the nurse instruct a client with tattooed eyeliner who is scheduled for an MRI?

1. Earplugs will be provided

2. Lie very still.

3. Report any burning sensation.

4. Wear goggles.

Correct Answer: 4

Rationale 1: Earplugs are offered to reduce the noise.

Rationale 2: One does have to lie still, but the damage could still occur to the eyes if they are not covered.

Rationale 3: Covering the eyes would prevent a complication of burning.

Rationale 4: The Society of Permanent Cosmetic Professionals states that the concentration of zinc oxide is low and diagnostic imaging problems are remote. Any potential problems can be avoided by wearing goggles to cover permanent cosmetics around the eyes.

Global Rationale: Page Reference: 829

Cognitive Level: Applying

Client Need:

Client Need Sub:

Nursing/Integrated Concepts:

Learning Outcome: 09 Compare and contrast CT, MRI, and nuclear imaging studies.

Question 18

Type: MCSA

For a lumbar puncture, the nurse should place the client in which position?

1. Lateral with head bent toward the chest and knees flexed onto the abdomen

2. Lying prone, with the knees drawn up toward the abdomen

3. Sitting bent over from the waist with legs extended

4. Supine with knees pulled toward the chest

Correct Answer: 1

Rationale 1: Lying in the lateral position with the head bent toward the chest and knees flexed onto the abdomen is the correct position for a lumbar puncture. In this position the back is arched, increasing the spaces between the vertebrae so that the spinal needle can be readily inserted.

Rationale 2: Lying prone with knees down toward the abdomen would position the client too high for the physician and could lead to increased intracranial pressure.

Rationale 3: Sitting would not arch the back enough to increase the space between the vertebrae for puncture.

Rationale 4: Supine with knees pulled toward the chest does not expose the vertebrae to be punctured.

Global Rationale: Page Reference: 831

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10 Describe the nurses role in caring for clients undergoing aspiration/biopsy procedures.

Question 19

Type: MCSA

What information should the nurse provide to a client who is scheduled to have abdominal ascites fluid removed?

1. A catheter will be inserted into the bladder

2. A liver biopsy will be done

3. An abdominal paracentesis will be done

4. A thoracentesis will be done

Correct Answer: 3

Rationale 1: Inserting a catheter into the bladder will only relieve urine, not the accumulation of fluid in the abdomen.

Rationale 2: A liver biopsy is performed to obtain a sample of the liver, not to remove fluid.

Rationale 3: An abdominal paracentesis is performed to remove ascites, which relieves pressure on the abdominal organs.

Rationale 4: A thoracentesis is performed to remove excess fluid or air to ease breathing.

Global Rationale: Page Reference: 831

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10 Describe the nurses role in caring for clients undergoing aspiration/biopsy procedures.

Question 20

Type: MCMA

What will the nurse do during the post-test phase of diagnostic testing for a client?

Standard Text: Select all that apply.

1. Provide emotional and physical support to the client.

2. Compare the previous and current test results.

3. Prepare the client for the test.

4. Modify nursing interventions as necessary.

5. Report the results to appropriate health team members.

Correct Answer: 2,4,5

Rationale 1: Providing emotional and physical support to the client is done during the intratest phase of diagnostic testing.

Rationale 2: During the post-test phase of diagnostic testing, the nurse will compare the previous and current test results.

Rationale 3: Preparing the client for the test is done during the pretest phase.

Rationale 4: During the post-test phase of diagnostic testing, the nurse will modify nursing interventions as necessary.

Rationale 5: During the post-test phase of diagnostic testing, the nurse will report the results to appropriate health team members.

Global Rationale: Page Reference: 808

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Describe the nurses role for each of the phases involved in diagnostic testing.

Question 21

Type: MCSA

The nurse needs to collect a specimen from a client. The nurse has never collected this type of specimen in the past. What should the nurse do?

1. Notify the physician.

2. Ask another nurse to collect the specimen.

3. Consult the nursing procedure manual.

4. Delegate the collection of the specimen to unlicensed assistive personnel.

Correct Answer: 3

Rationale 1: The nurse should not notify the physician.

Rationale 2: The nurse should not ask another nurse to collect the specimen.

Rationale 3: A nursing procedure or laboratory manual is often available if the nurse is unfamiliar with the procedure. If there is any question about the procedure, the nurse should call the laboratory for directions before collecting the specimen.

Rationale 4: The nurse should not delegate the collection of the specimen to unlicensed assistive personnel.

Global Rationale: Page Reference: 808

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Discuss the nursing responsibilities for specimen collection.

Question 22

Type: MCSA

An older client is having difficulty handling the specimen cup for a clean catch urine specimen. What can the nurse do to help this client?

1. Provide a clean funnel to pour the urine into the specimen cup.

2. Document that the specimen could not be obtained.

3. Catheterize the client for the specimen.

4. Ask the physician to obtain the specimen.

Correct Answer: 1

Rationale 1: If an older client is having difficulty with a specimen cup for a clean catch urine specimen, the nurse should provide a clean funnel to pour the urine into the container.

Rationale 2: The nurse should not document that the specimen could not be obtained.

Rationale 3: The nurse needs a physicians order to catheterize the client for the specimen.

Rationale 4: Obtaining urine specimens is a nursing responsibility, and should not be delegated to the physician.

Global Rationale: Page Reference: 821

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Verbalize the steps used in:
b. Collecting a urine specimen for culture and sensitivity by clean catch.

Question 23

Type: MCSA

A client is scheduled for a nuclear imaging test. What should the nurse instruct the client about this test?

1. It is the use of a magnetic field to produce an image of a body part or organ.

2. A radioisotope will be injected to determine organ functioning as being either hot or cold.

3. It produces a three-dimensional image of an organ.

4. It is more sensitive than an x-ray image.

Correct Answer: 2

Rationale 1: The MRI uses a magnetic field to produce an image of a body part or organ.

Rationale 2: In nuclear imaging studies, a radioisotope is injected, and the body organ is determined as functioning as either hot or cold.

Rationale 3: The CT scan produces a three-dimensional image of an organ.

Rationale 4: The CT scan is more sensitive than an x-ray image.

Global Rationale: Page Reference: 828

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Compare and contrast CT, MRI, and nuclear imaging studies.

Question 24

Type: MCMA

The nurse is instructing a female client how to cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity. What should the nurse instruct this client to do?

Standard Text: Select all that apply.

1. Clean the perineal area using a circular motion.

2. Use all towlettes provided.

3. Use each towlette once, and discard.

4. Clean the perineal area from back to front.

5. Clean the perineal area from front to back.

Correct Answer: 2,3,5

Rationale 1: Cleaning the perineal area using a circular motion would be appropriate for a male client.

Rationale 2: To cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity for a female client, the client should be instructed to use all towlettes provided.

Rationale 3: To cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity for a female client, the client should be instructed to use each towlette once and discard.

Rationale 4: Cleaning the perineal area from back to front introduces bacteria from the anal region towards the perineum.

Rationale 5: To cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity for a female client, the client should be instructed to clean the perineal area from front to back.

Global Rationale: Page Reference: 821

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Verbalize the steps used in:
b. Collecting a urine specimen for culture and sensitivity by clean catch.

Question 25

Type: MCMA

Unlicensed assistive personnel (UAP) will be conducting a test on a clients urine. What should the nurse instruct the UAP about the test?

Standard Text: Select all that apply.

1. Nothing, since the UAP can perform urine testing.

2. Remind the UAP to tell the client the results of the test.

3. Notify the physician with the results of the test.

4. Report the results of the test to the nurse.

5. Save the urine, in case the nurse wants to repeat the test.

Correct Answer: 4,5

Rationale 1: The nurse needs to instruct the UAP to report the results to the nurse and save the urine.

Rationale 2: The UAP is not to tell the client the results of the test.

Rationale 3: The nurse is to notify the physician with the results of the test.

Rationale 4: The nurse should instruct the UAP to report the results of the test to the nurse.

Rationale 5: The nurse should instruct the UAP to save the urine in case the nurse wants to repeat the test.

Global Rationale: Page Reference: 821-822

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Compare and contrast the different types of urine specimens.
12 Recognize when it is appropriate to delegate diagnostic testing skills to unlicensed assistive personnel.

Question 26

Type: MCSA

A client is having a timed urine collection done. The unlicensed assistive personnel does not save one specimen. What should the nurse do?

1. Continue with the test, and document that one specimen is missing.

2. End the test immediately, and send what is collected to the laboratory.

3. Document that the test cannot be completed.

4. Start the test over.

Correct Answer: 4

Rationale 1: The test cannot be continued, and it should not be documented that one specimen is missing.

Rationale 2: The test is not to be ended immediately, and the specimen should not be sent to the laboratory. The test is not complete.

Rationale 3: The nurse should not document that the test cannot be completed. It needs to be restarted.

Rationale 4: If the client or staff forgets and discards the clients urine during a timed collection, the procedure must be restarted from the beginning.

Global Rationale: Page Reference: 824

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Compare and contrast the different types of urine specimens.

Question 27

Type: MCMA

The nurse is caring for a client who has just had a lumbar puncture. What should the nurse document about this clients procedure?

Standard Text: Select all that apply.

1. Date and time performed.

2. The physicians name.

3. The clients ability to void after the procedure.

4. The color, character, and amount of cerebrospinal fluid withdrawn.

5. The clients status after the procedure.

Correct Answer: 1,2,4,5

Rationale 1: When documenting after a lumbar procedure, the nurse should include the date and time the procedure was performed.

Rationale 2: When documenting after a lumbar procedure, the nurse should include the physicians name.

Rationale 3: The nurse does not need to assess the clients ability to void after the procedure, since the lumbar puncture is done through the spinal column and not the abdominal region.

Rationale 4: When documenting after a lumbar procedure, the nurse should include the color, character, and amount of cerebrospinal fluid withdrawn.

Rationale 5: When documenting after a lumbar procedure, the nurse should include the clients status after the procedure.

Global Rationale: Page Reference: 834

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10 Describe the nurses role in caring for clients undergoing aspiration/biopsy procedures.
13 Demonstrate appropriate documentation and reporting of diagnostic testing information.

Question 28

Type: MCMA

A client has just completed a bone marrow biopsy. What should the nurse document about the client at this time?

Standard Text: Select all that apply.

1. Clients tolerance of the procedure.

2. Bowel sounds.

3. The site for bleeding.

4. Status of deep tendon reflexes.

5. Presence of pain and any pain medication received.

Correct Answer: 1,3,5

Rationale 1: The nurse should document how well the client tolerated the procedure, since it can cause considerable discomfort.

Rationale 2: Bowel sounds are not a part of the assessment after a bone marrow biopsy.

Rationale 3: The nurse should document the bone marrow biopsy site for bleeding, since this can occur.

Rationale 4: Deep tendon reflexes are not part of the assessment after a bone marrow biopsy.

Rationale 5: The nurse should document whether the client is experiencing any pain, and whether any pain medication was provided.

Global Rationale: Page Reference: 837

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10 Describe the nurses role in caring for clients undergoing aspiration/biopsy procedures.
13 Demonstrate appropriate documentation and reporting of diagnostic testing information.

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

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