NCLEX Review Adult Health ~ 52 Selected Lab & Diagnostic Tests Questions Nursing Considerations &...

NCLEX Review

Adult Health

~ 52 Selected Lab & Diagnostic Tests Questions

Nursing Considerations & Safety

Questions and Answers

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1. A client’s laboratory results reveal a hemoglobin of 6 g/dL. Which foods should be encouraged for this client?


A. Broiled fishB. Whole grainsC. Dried fruitsD. Steamed vegetables


C. With a low hemoglobin, the oxygen-carrying capacity of the blood is diminished resulting in client fatigue. The preserving agent for dried fruits adds iron, making the fruits excellent sources for this mineral.

C. With a low hemoglobin, the oxygen-carrying capacity of the blood is diminished resulting in client fatigue. The preserving agent for dried fruits adds iron, making the fruits excellent sources for this mineral.





Normal Hgb range ~ 14-17 g/dl

2. Which nursing diagnosis is most appropriate for a female adult client with a hemoglobin of 12.0 mg/dL and a hematocrit of 29%?

A. Fluid volume excess

B. Decreased tissue perfusion

C. Impaired tissue integrity

D. Risk for activity intolerance

2. Which nursing diagnosis is most appropriate for a female adult client with a hemoglobin of 12.0 mg/dL and a hematocrit of 29%?

A. Fluid volume excess

B. Decreased tissue perfusion

C. Impaired tissue integrity

D. Risk for activity intolerance

A. Hemoglobin is normal. Hematocrit should be 3 times the hemoglobin. If it is less than that, it indicates over hydration or hemodilution.

Normal Hgb range ~ 14-17 g/dl

Normal Hct ~ 36-50% (males higher than females)

3. The reticulocyte count is elevated in a client with recent blood loss due to severe skin laceration. In planning care, the RN anticipates which physician order?

A. Maintain fluid intake at 2-3 liters per day

B. Obtain consent for bone marrow biopsy

C. Institute iron restricted diet

D. Prepare client for plasmaphoresis

3. The reticulocyte count is elevated in a client with recent blood loss due to severe skin laceration. In planning care, the RN anticipates which physician order?

A. Maintain fluid intake at 2-3 liters per day

B. Obtain consent for bone marrow biopsy

C. Institute iron restricted diet

D. Prepare client for plasmaphoresis

A. Increased reticulocyte count is normal after blood loss or in anemia. It indicates the bone marrow is working to replace lost RBCs by producing immature RBCs and sending them into the circulation.

4. Which statement would be true of platelets?

A. Are formed and stored in the spleen

B. Repair damage to small blood vessels

C. Cause red blood cells to clump forming clots

D. Circulate for 4-6 weeks before dying

4. Which statement would be true of platelets?

A. Are formed and stored in the spleen

B. Repair damage to small blood vessels

C. Cause red blood cells to clump forming clots

D. Circulate for 4-6 weeks before dying

B. Platelets repair damage to small blood vessels. They are formed in the bone marrow but are stored in the spleen and clump together to form clots. They live 1-2 weeks.

Normal count = 150,000-450,000

5. Which is an explanation for a shift-to-the-left in the neutrophil count?

A. Stem cells are being over produced

B. Bone marrow is releasing fewer mature cells into the circulating blood

C. Bone marrow is responding to overproduction of lymphocytes

D. The thymus gland is unable to produce T-cells

5. Which is an explanation for a shift-to-the-left in the neutrophil count?

A. Stem cells are being over produced

B. Bone marrow is releasing fewer mature cells into the circulating blood

C. Bone marrow is responding to overproduction of lymphocytes

D. The thymus gland is unable to produce T-cells

B. This is the only response related to neutrophil shift-to-the-left.

6. Which of these clients should the nurse assess first?

A. Hemoglobin level of 15.9 g/dL

B. Coumadin with a prothrombin time (PT) of 35.6 seconds

C. Total calcium level of 9.4 mg/dL

D. BUN of 30 mg/dL and creatinine of 1.1 mg/dL

6. Which of these clients should the nurse assess first?

A. Hemoglobin level of 15.9 g/dL

B. Coumadin with a prothrombin time (PT) of 35.6 seconds

C. Total calcium level of 9.4 mg/dL

D. BUN of 30 mg/dL and creatinine of 1.1 mg/dL

B. Normal prothrombin time is <13 seconds and on coumadin therapy, it should be 1.5-2.5 times greater. This client has 3 times greater time and so is at risk.

Normal Ca++ ` 9-10.5 mg / dl

Normal BUN ~ 7-20 mg / dl Normal Creat ~ 0.5-1.5 mg/dl

7. Which client is most likely to have an elevated erythrocyte sedimentation rate?

A. Congestive heart failure

B. Glaucoma

C. Hypertension

D. Pregnancy

7. Which client is most likely to have an elevated erythrocyte sedimentation rate?

A. Congestive heart failure

B. Glaucoma

C. Hypertension

D. Pregnancy

D. This is the only correct answer.

^ ESR ~ inflammation

8. Which does not specifically increase HDL cholesterol levels?

A. Smoking cessation

B. Nicotinic acid

C. Lipitor (atorvastatin)

D. Exercise

8. Which does not specifically increase HDL cholesterol levels?

A. Smoking cessation

B. Nicotinic acid

C. Lipitor (atorvastatin)

D. Exercise

C. Lipitor decreases LDL and triglycerides. Stopping smoking, nicotinic acid or niacin, and exercise raise HDL levels.

9. After receiving report of four clients at 7:00 a.m., which task should the nurse complete first?

A. Call physician to request antiemetic for client who has been vomiting

B. Notify family of a client’s transfer to ICU for chest pain

C. Call a potassium level of 5.9 to the attention of the physician

D. Begin routine assessment rounds, starting with the sickest client

9. After receiving report of four clients at 7:00 a.m., which task should the nurse complete first?

A. Call physician to request antiemetic for client who has been vomiting

B. Notify family of a client’s transfer to ICU for chest pain

C. Call a potassium level of 5.9 to the attention of the physician

D. Begin routine assessment rounds, starting with the sickest client

C. A potassium level of 5.9 is life threatening.

normal serum K+ = 3.5-5.5

10.The nurse is reviewing laboratory test results for a client with severe crush injuries of both lower extremities secondary to a motor vehicle accident. Which result causes the nurse the most concern?

A. Blood urea nitrogen of 18 mg/dL

B. Serum creatinine level of 1.2 mg/dL

C. White blood cell count of 9000/cu mm

D. Serum potassium of 6.0 mEq/dL

10.The nurse is reviewing laboratory test results for a client with severe crush injuries of both lower extremities secondary to a motor vehicle accident. Which result causes the nurse the most concern?

A. Blood urea nitrogen of 18 mg/dL

B. Serum creatinine level of 1.2 mg/dL

C. White blood cell count of 9000/cu mm

D. Serum potassium of 6.0 mEq/dL

D. Hyperkalemia can lead to serious cardiac dysrhythmias such as ventricular fibrillation or cardiac standstill. The other lab values are within acceptable parameters.

normal serum K+ = 3.5-5.5

Normal BUN ~ 7-20 mg / dl Normal Creat ~ 0.5-1.5 mg/dl

Normal WBC Count ~4300 to 10800

11. A 27-year-old construction worker is admitted to the Urgent Care Center with tachycardia, hypotension, weakness, decreased DTRs, headache, and agitation. The client’s skin is moist and warm, the urine specific gravity is 1.030, and loose stools have occurred. The outside temperature is 98o F (36.67o C) and the client has consumed 1.5 liters of water in the last 30 minutes. What is the most likely cause of the symptoms?

A. Hypokalemia

B. Hyponatremia

C. Hypercalcemia

D. Hypomagnesemia

11. A 27-year-old construction worker is admitted to the UrgentCare Center with tachycardia, hypotension, weakness, decreased DTRs, headache, and agitation. The client’s skin is moist and warm, the urine specific gravity is 1.030, and loose stools have occurred. The outside temperature is 98o F (36.67o C) and the client has consumed 1.5 liters of water in the last 30 minutes. What is the most likely cause of the symptoms?

A. Hypokalemia

B. Hyponatremia

C. Hypercalcemia

D. Hypomagnesemia

B. With heat, excessive sweating produces sodium and water loss. The water consumed has no electrolytes and the symptoms are consistent with hyponatremia and hypovolemia.

Normal SG~ 1.002 and 1.035

12. A client with a calcium level of 12.1 mg/dL is at risk for which problem?

A. Renal calculi

B. Osteoporosis

C. Dental caries

D. Rickets

12. A client with a calcium level of 12.1 mg/dL is at risk for which problem?

A. Renal calculi

B. Osteoporosis

C. Dental caries

D. Rickets

A. This is an elevated level of calcium and may contribute to the formation of kidney stones.

Normal Ca++ ` 9-10.5 mg / dl

13. Major trauma to skeletal muscle tissue would not cause an increase in which lab value?

A. Alkaline phosphatase

B. CK-MM

C. LDH

D. AST

13. Major trauma to skeletal muscle tissue would not cause an increase in which lab value?

A. Alkaline phosphatase

B. CK-MM

C. LDH

D. AST

A. Alkaline phosphatase increases with bone trauma. The other values increase with muscle trauma or necrosis.

14. A voided urinalysis result shows numerous epithelial cells, bacteria, and leukocytes, but all other indices are normal. Which intervention is appropriate at this time?

A. Notify the physician as this indicates an infection

B. Assess for allergy to antibiotics

C. Obtain a 2nd urinalysis using a clean-catch method

D. Perform a catheterized urinalysis

14. A voided urinalysis result shows numerous epithelial cells, bacteria, and leukocytes, but all other indices are normal. Which intervention is appropriate at this time?

A. Notify the physician as this indicates an infection

B. Assess for allergy to antibiotics

C. Obtain a 2nd urinalysis using a clean-catch method

D. Perform a catheterized urinalysis

C. This is most likely a contaminated specimen without proper cleansing before collection.

15. A client is admitted for a cholecystectomy with a creatinine level of 1.0 mg/dL and BUN of 22 mg/dL. Which medication order would the nurse question?

A. Demerol 50 mg IM every 3-4 hours PRN severe pain

B. Glucophage (metformin) 500 mg PO every day

C. Carafate (sucralfate) 1 gm PO qid 1 hour ac and hs

D. Lopressor (metoprolol) 100 mg PO every day

15. A client is admitted for a cholecystectomy with a creatinine level of 1.0 mg/dL and BUN of 22 mg/dL. Which medication order would the nurse question?

A. Demerol 50 mg IM every 3-4 hours PRN severe pain

B. Glucophage (metformin) 500 mg PO every day

C. Carafate (sucralfate) 1 gm PO qid 1 hour ac and hs

D. Lopressor (metoprolol) 100 mg PO every day

B. Glucophage can lead to liver failure if the client goes into metabolic acidosis (related to renal compromise).

16. The nurse is completing the admission history of a client who is to undergo an intravenous pyelogram (IVP). Which client statement would be cause for concern?


A. “I received penicillin as a child and it has made me sick ever since.”

B. “I had a bad experience after eating seafood last year, so I avoid it.”

C. “My doctor says I shouldn’t eat eggs because they can help clog my arteries.”

D. “The last time I had a special test, there was a salty taste when they gave me the dye.”





B. Iodine-containing contrast media may be used for the IVP. Many people who are allergic to seafood, are allergic to iodine. If this allergy is present, an anaphylactic reaction can occur during the IVP.

***also, think about oral hypoglycemics…

B. Iodine-containing contrast media may be used for the IVP. Many people who are allergic to seafood, are allergic to iodine. If this allergy is present, an anaphylactic reaction can occur during the IVP.

***also, think about oral hypoglycemics…











17. The client asks the nurse about special preparation for an ultrasound of the kidneys. Which response by the nurse is most appropriate?


A. “Radiopaque dye will be used to help visualize the kidney.”B. “The puncture site will be monitored frequently for

bleeding.”C. “No special preparation is required for this test.”D. “There will be no food or fluid for 12 hours prior to the test.”

A. “Radiopaque dye will be used to help visualize the kidney.”B. “The puncture site will be monitored frequently for

bleeding.”C. “No special preparation is required for this test.”D. “There will be no food or fluid for 12 hours prior to the test.”

C. An ultrasound exam is a noninvasive test that, in most cases, requires no special preparation except a full bladder.

C. An ultrasound exam is a noninvasive test that, in most cases, requires no special preparation except a full bladder.



A. “Radiopaque dye will be used to help visualize the kidney.”B. “The puncture site will be monitored frequently for bleeding.”C. “No special preparation is required for this test.”D. “There will be no food or fluid for 12 hours prior to the test.”

A. “Radiopaque dye will be used to help visualize the kidney.”B. “The puncture site will be monitored frequently for bleeding.”C. “No special preparation is required for this test.”D. “There will be no food or fluid for 12 hours prior to the test.”

18. A 43-year-old anxious client is to receive teaching prior to a cystoscopy. Which part of the teaching plan indicates the need for clarification prior to talking to the client?

A. Assess client understanding of the procedure before witnessing the consent form

B. Teach client that general anesthesia will likely be used

C. Client may have only clear liquids the evening before the procedure

D. A bowel prep with laxatives will be completed before the procedure

18. A 43-year-old anxious client is to receive teaching prior to a cystoscopy. Which part of the teaching plan indicates the need for clarification prior to talking to the client?

A. Assess client understanding of the procedure before witnessing the consent form

B. Teach client that general anesthesia will likely be used

C. Client may have only clear liquids the evening before the procedure

D. A bowel prep with laxatives will be completed before the procedure

C. The client may have a light evening meal, then will be NPO after midnight if general anesthesia is used.

19. After cystoscopy, the RN monitors the client for development of post-procedural complications. Which symptom would be most expected?

A. Urinary frequency and dysuria

B. Hypertension and polydipsia

C. Hematuria and hypotension

D. Orange discoloration to urine and bladder spasm

19. After cystoscopy, the RN monitors the client for development of post-procedural complications. Which symptom would be most expected?

A. Urinary frequency and dysuria

B. Hypertension and polydipsia

C. Hematuria and hypotension

D. Orange discoloration to urine and bladder spasm

A. The most common complication is urinary tract infection due to instrumentation in the procedure.

20. A client with a goiter has a TSH of 0.3 mU/L. The RN would expect which symptoms?

A. Weight gain, fatigue and bradycardia

B. Headache, diplopia and tinnitis

C. Bruit upon auscultation of thyroid and hypertension

D. Hypernatremia and decreased urine specific gravity

20. A client with a goiter has a TSH of 0.3 mU/L. The RN would expect which symptoms?

A. Weight gain, fatigue and bradycardia

B. Headache, diplopia and tinnitis

C. Bruit upon auscultation of thyroid and hypertension

D. Hypernatremia and decreased urine specific gravity

C. Bruits are often heard with goiter and the hyperthyroidism causes increase in systolic blood pressure and decrease in thyroid stimulating hormone (TSH). A is hypothyroidism. Normal TSH is 0.4-4.2 mU/L.

21. A client with hypothyroidism is on hormone replacement. Which is true concerning abnormal TSH levels?

A. As the T3 and T4 levels drop, TSH also decreases as a result of the positive feedback loop

B. After initiation of Synthroid (levothyroxine) the TSH level decreases gradually as a result of the negative feedback loop

C. Synthroid (levothyroxine) works primarily by converting T3

into T4 and as blood levels rise, TSH levels drop

D. As the TSH level rises after treatment is started with Synthroid (levothyroxine), calcitonin levels rise and thyroid function normalizes

21. A client with hypothyroidism is on hormone replacement. Which is true concerning abnormal TSH levels?

A. As the T3 and T4 levels drop, TSH also decreases as a result of the positive feedback loop

B. After initiation of Synthroid (levothyroxine) the TSH level decreases gradually as a result of the negative feedback loop

C. Synthroid (levothyroxine) works primarily by converting T3 into T4 and as blood levels rise, TSH levels drop

D. As the TSH level rises after treatment is started with Synthroid (levothyroxine), calcitonin levels rise and thyroid function normalizes

B. This is the only true statement.

22. Which client could have a thyroid scan?

A. Allergic to shellfish and betadine

B. 24 weeks pregnant

C. Breastfeeding a 6 week old baby

D. Completed steroid treatment 3 weeks ago

22. Which client could have a thyroid scan?

A. Allergic to shellfish and betadine

B. 24 weeks pregnant

C. Breastfeeding a 6 week old baby

D. Completed steroid treatment 3 weeks ago

D. Radioactive iodine may be used 21 days after discontinuing corticosteroids.

23. A 43-year-old obese female client has a fasting blood sugar of 140 mg/dL and states her blood glucose has never been elevated before. Which is the top priority?

A. Potential for hypoglycemia

B. Risk for injury related to hyperglycemia

C. Knowledge deficit related to disease process

D. Potential for ineffective individual coping

23. A 43-year-old obese female client has a fasting blood sugar of 140 mg/dL and states her blood glucose has never been elevated before. Which is the top priority?

A. Potential for hypoglycemia

B. Risk for injury related to hyperglycemia

C. Knowledge deficit related to disease process

D. Potential for ineffective individual coping

C. Potential problems and risks are secondary priorities. The client has an existing knowledge deficit related to this newly diagnosed diabetes mellitus (FBS>126 mg/dL is diagnostic).

24. A 16-year-old client with type I Diabetes Mellitus is sporadically non-compliant with diet and today’s FBS was 116 mg/dL. Which glycosylated hemoglobin would indicate a need for more teaching?

A. Hgb A1C is 2.5%

B. Hgb A1C is 6.5%

C. Hgb A1C has increased from 5.9% to 7.9%

D. Hgb A1C has dropped from 4% to 2.5%

24. A 16-year-old client with type I Diabetes Mellitus is sporadically non-compliant with diet and today’s FBS was 116 mg/dL. Which glycosylated hemoglobin would indicate a need for more teaching?

A. Hgb A1C is 2.5%

B. Hgb A1C is 6.5%

C. Hgb A1C has increased from 5.9% to 7.9%

D. Hgb A1C has dropped from 4% to 2.5%

C. Normal Hgb A1C for a diabetic in good control is 6-7%. An increase of 2% and over the normal indicates a need for more teaching.

25. A pregnant client at 28 weeks gestation has a fasting 1 hour glucose challenge test with a result of 156 mg/dL. Which would be the best response by the nurse?

A. Tell her she has diabetes mellitus and plan teaching

B. Order a 3 hour glucose tolerance test per protocol

C. Continue to monitor her as this is normal

D. Continue to monitor the elevated placental lactogen

25. A pregnant client at 28 weeks gestation has a fasting 1 hour glucose challenge test with a result of 156 mg/dL. Which would be the best response by the nurse?

A. Tell her she has diabetes mellitus and plan teaching

B. Order a 3 hour glucose tolerance test per protocol

C. Continue to monitor her as this is normal

D. Continue to monitor the elevated placental lactogen

B. If the GCT is above 140 mg/dL, a 3 hour GTT is indicated. Also, it should be done non-fasting.

26. The nurse is asked to collect a sample of exudate from a client’s wound for a culture and sensitivity. What procedure would be best?

A. Irrigate the wound and then collect sample

B. Place sample in sterile container for transport

C. Start the ordered antibiotic and then collect sample

D. Swab the skin around the wound to collect sample

26. The nurse is asked to collect a sample of exudate from a client’s wound for a culture and sensitivity. What procedure would be best?

A. Irrigate the wound and then collect sample

B. Place sample in sterile container for transport

C. Start the ordered antibiotic and then collect sample

D. Swab the skin around the wound to collect sample

B. All specimens must be collected using sterile methods and placed in a sterile container. Antibiotics should be started after specimen collection.

27. Which client would the nurse send for an MRI without questioning the order?

A. Diabetic with an implanted insulin pump

B. Pregnant primigravida at 34 weeks gestation

C. Client with heart failure and a pacemaker

D. Auto accident victim on life support systems

27. Which client would the nurse send for an MRI without questioning the order?

A. Diabetic with an implanted insulin pump

B. Pregnant primigravida at 34 weeks gestation

C. Client with heart failure and a pacemaker

D. Auto accident victim on life support systems

B. Pregnancy is not a contraindication for MRI. The other options have equipment containing metal which would cause the MRI equipment to malfunction.

28. Which consideration would be least important when a client is to have computed tomography (CT) scan with contrast medium?

A. Client has Huntington disease

B. Client has chronic renal failure

C. Client had hives following an IVP

D. Client ate lunch 5 hours ago

28. Which consideration would be least important when a client is to have computed tomography (CT) scan with contrast medium?

A. Client has Huntington disease

B. Client has chronic renal failure

C. Client had hives following an IVP

D. Client ate lunch 5 hours ago

D. Clients are usually NPO for no more than 4 hours before the test. The client must lie still and must be able to clear the contrast medium without reacting negatively to it.

29. What follow-up care is needed for a client with PAP(Papanicolaou test) results of "atypical squamous cells of undetermined significance“ (ASCUS)?

29. What follow-up care is needed for a client with PAP(Papanicolaou test) results of "atypical squamous cells of undetermined significance“ (ASCUS)?

A. Normal report and requires no special follow-upB. Indicates cancerous cells; client will have an immediate

colonoscopyC. Abnormal report; client will need follow-up evaluationD. Indicates cancerous cells; client will require a

hysterectomy


colonoscopyC. Abnormal report; client will need follow-up evaluationD. Indicates cancerous cells; client will require a

hysterectomy

C. This is not a normal report and indicates that further information is needed before a diagnosis of cancer is made.

C. This is not a normal report and indicates that further information is needed before a diagnosis of cancer is made.

29. What follow-up care is needed for a client with PAP (Papanicolaou test) results of "atypical squamous cells of undetermined significance“ (ASCUS)?

29. What follow-up care is needed for a client with PAP (Papanicolaou test) results of "atypical squamous cells of undetermined significance“ (ASCUS)?


colonoscopyC. Abnormal report; client will need follow-up evaluationD. Indicates cancerous cells; client will require a hysterectomy


colonoscopyC. Abnormal report; client will need follow-up evaluationD. Indicates cancerous cells; client will require a hysterectomy

30. A 42-year-old female client asks the RN when she should have a mammogram. What is the RN’s best reply based on current American Cancer Society recommendations?

A. “Have a baseline mammogram between age 40 and 45.”

B. “Begin having annual mammograms now.”

C. “Begin having annual mammograms at age 50.”

D. “Begin having mammograms every other year now.”

30. A 42-year-old female client asks the RN when she should have a mammogram. What is the RN’s best reply based on current American Cancer Society recommendations?

A. “Have a baseline mammogram between age 40 and 45.”

B. “Begin having annual mammograms now.”

C. “Begin having annual mammograms at age 50.”

D. “Begin having mammograms every other year now.”

B. According to the American Cancer Society, women should begin having annual mammograms at age 40.

31. Which client statement indicates a need for further teaching regarding a mammogram?

A. “I will not bathe on the morning of the procedure.”

B. “I will not apply deodorant before the procedure.”

C. “I will experience some discomfort from the compression of the tissue during the procedure.”

D. “I will be asked to remove my clothing from the waist up prior to this procedure.”

31. Which client statement indicates a need for further teaching regarding a mammogram?

A. “I will not bathe on the morning of the procedure.”

B. “I will not apply deodorant before the procedure.”

C. “I will experience some discomfort from the compression of the tissue during the procedure.”

D. “I will be asked to remove my clothing from the waist up prior to this procedure.”

A. Clients may bathe before a mammogram. However, they should be instructed not to wear lotions, powders, or deodorants as these may contain metallic salts.

32. What is the rationale for including the step of inspection of the breasts with the arms raised above the head when performing breast self examination?

A. Facilitates inspection of axillary lymph nodes

B. Triggers spontaneous nipple discharge

C. Elevates nipple and areolar area

D. Reveals changes in breast contour and symmetry

32. What is the rationale for including the step of inspection of the breasts with the arms raised above the head when performing breast self examination?

A. Facilitates inspection of axillary lymph nodes

B. Triggers spontaneous nipple discharge

C. Elevates nipple and areolar area

D. Reveals changes in breast contour and symmetry

D. Changes in shape or contour are emphasized when the arms are raised over the head.

33. How would the nurse best teach a client about an endometrial biopsy?

A. Will require an overnight hospital stay

B. A tube will be inserted into the uterus through the abdomen

C. There will be cramping during the procedure

D. A magnifying instrument will allow tissue visualization

33. How would the nurse best teach a client about an endometrial biopsy?

A. Will require an overnight hospital stay

B. A tube will be inserted into the uterus through the abdomen

C. There will be cramping during the procedure

D. A magnifying instrument will allow tissue visualization

C. There will be cramping when the biopsy is taken. The procedure is done in an office or clinic by placing a tube thru the cervix into the uterine body. Tissue is not visualized.

34. A colposcopy is scheduled for a client. In reviewing the client’s chart, which would the RN expect in the history?

A. History of infertility

B. History of abnormal PAP smear

C. Family history of ovarian cancer

D. History of cervical laceration

34. A colposcopy is scheduled for a client. In reviewing the client’s chart, which would the RN expect in the history?

A. History of infertility

B. History of abnormal PAP smear

C. Family history of ovarian cancer

D. History of cervical laceration

B. Colposcopy is used to locate the exact site of precancerous and malignant lesions for tissue biopsy following an abnormal PAP smear.

35. A client had a laparoscopic tubal ligation this morning. Which nursing diagnosis has the highest priority?

A. Pain related to CO2 insufflation

B. Activity intolerance related to post-anesthesia fatigue

C. Risk for infection related to surgical incision

D. Risk for altered tissue perfusion related to surgical procedure

35. A client had a laparoscopic tubal ligation this morning. Which nursing diagnosis has the highest priority?

A. Pain related to CO2 insufflation

B. Activity intolerance related to post-anesthesia fatigue

C. Risk for infection related to surgical incision

D. Risk for altered tissue perfusion related to surgical procedure

A. Carbon dioxide gas is used to separate the internal structures for better visualization and the remaining gas stimulates the diaphragm resulting in left shoulder pain.

36. A teenage client who is scheduled for a lumbar puncture, was told by friends that “the brain sinks” when cerebrospinal fluid is removed. Choose the best response by the nurse to lower anxiety levels.

A. “Removing the small amount of CSF during the procedure has absolutely no effect on the brain.”

B. “The amount of CSF removed will be rapidly replaced by the body.”

C. “The body has more fluid than is necessary and the amount removed is insignificant.”

D. “The physician will monitor the CSF pressure closely during the procedure to minimize any danger.”

36. A teenage client who is scheduled for a lumbar puncture, was told by friends that “the brain sinks” when cerebrospinal fluid is removed. Choose the best response by the nurse to lower anxiety levels.

A. “Removing the small amount of CSF during the procedure has absolutely no effect on the brain.”

B. “The amount of CSF removed will be rapidly replaced by the body.”

C. “The body has more fluid than is necessary and the amount removed is insignificant.”

D. “The physician will monitor the CSF pressure closely during the procedure to minimize any danger.”

• Clarification of how the body works is reassuring to the client.

37. Which statement would best assist a client to prepare for a cerebral angiogram?

A. “This X-ray will help assess the circulation around your heart.”

B. “You will have a regular breakfast before the test.”

C. “A contrast dye will be injected to help visualize the blood vessels.”

D. “The catheter will be inserted in your left arm close to the heart.”

37. Which statement would best assist a client to prepare for a cerebral angiogram?

A. “This X-ray will help assess the circulation around your heart.”

B. “You will have a regular breakfast before the test.”

C. “A contrast dye will be injected to help visualize the blood vessels.”

D. “The catheter will be inserted in your left arm close to the heart.”

• A contrast dye will be inserted through the groin to visualize the vessels in the brain. Clients are either NPO or have only clear liquids 6-8 hours before the procedure.

38. Which statement would be representative of a normal electrocardiogram (EKG)?

A. QRS complex of .08 seconds

B. PR interval of .05 seconds

C. P wave of .14 seconds

D. Total heart beat of 4 seconds

38. Which statement would be representative of a normal electrocardiogram (EKG)?

A. QRS complex of .08 seconds

B. PR interval of .05 seconds

C. P wave of .14 seconds

D. Total heart beat of 4 seconds

• The normal QRS complex is .06-.10 seconds. PR interval should be .12-.20 seconds and P wave should be less than .11 seconds. The normal heart beat is about .20-.40 seconds.

39. The nurse is reviewing laboratory tests of a client who was admitted with chest pain. Which result should the nurse report to the physician immediately?

A. Elevation in serum troponin level

B. Decrease in serum troponin level

C. Elevation in blood urea nitrogen level

D. Decrease in serum creatinine level

39. The nurse is reviewing laboratory tests of a client who was admitted with chest pain. Which result should the nurse report to the physician immediately?

• A. Elevation in serum troponin levelB. Decrease in serum troponin level C. Elevation in blood urea nitrogen levelD. Decrease in serum creatinine level

• A. Cardiac troponin is virtually undetectable in the serum of healthy people, but rises to a detectable level within 1 hour of myocardial injury. It is especially useful in the early diagnosis of acute MI and in detection of “silent” MI.

40. During a treadmill stress test, a middle-aged client becomes extremely diaphoretic and complains of pressure in the mid-chest. The nurse notes the ST segment is elevated on the EKG. What is the nurse’s first action?

A. Offer a glass of cool water to help replace fluid lost by sweating

B. Have the client take a break and give the morning dose of digoxin (Lanoxin)

C. Continue the test at a slower rate and notify the physician

D. Stop the test, have the client sit or lie down and assess vital signs

40. During a treadmill stress test, a middle-aged client becomes extremely diaphoretic and complains of pressure in the mid-chest. The nurse notes the ST segment is elevated on the EKG. What is the nurse’s first action?

A. Offer a glass of cool water to help replace fluid lost by sweating

B. Have the client take a break and give the morning dose of digoxin (Lanoxin)

C. Continue the test at a slower rate and notify the physician

D. Stop the test, have the client sit or lie down and assess vital signs

• D. These symptoms and EKG changes may indicate the onset of an MI and any farther activity will worsen the condition.

41. The nurse is teaching a client who is scheduled for 24-hour Holter monitoring. Which client statement indicates that the teaching was successful?

A. “I should remain as still as possible while wearing the monitor.”

B. “I will keep a log of daily activities while I am wearing the monitor.”

C. “I will avoid physical strain while I am wearing the monitor.”

D. “I will avoid using caffeine while wearing the monitor.”

41. The nurse is teaching a client who is scheduled for 24-hour Holter monitoring. Which client statement indicates that the teaching was successful?

A. “I should remain as still as possible while wearing the monitor.”

B. “I will keep a log of daily activities while I am wearing the monitor.”

C. “I will avoid physical strain while I am wearing the monitor.”

D. “I will avoid using caffeine while wearing the monitor.”

• B. The client should maintain a daily schedule as close to normal as possible while wearing a Holter monitor, and should continue the usual diet. It is important for the client to record all activities while being monitored, for comparison of the activities with EKG tracings during analysis of the data.

42. What statement would best describe an echocardiogram?

A. Percussive tapping of the chest over the heart

B. Noninvasive ultrasound of the lungs

C. Invasive electroconduction examination

D. Sonographic examination of the heart

42. What statement would best describe an echocardiogram?

A. Percussive tapping of the chest over the heart

B. Noninvasive ultrasound of the lungs

C. Invasive electroconduction examination

D. Sonographic examination of the heart

• D. Echocardiogram is a noninvasive ultrasound or sonograph of the heart for visualization purposes.

43. Following cardiac catheterization, what nursing diagnosis would be the most appropriate?

A. Risk for clot displacement

B. Risk for fluid volume deficit

C. Risk for situational fear

D. Risk for disturbed individual coping

43. Following cardiac catheterization, what nursing diagnosis would be the most appropriate?

A. Risk for clot displacement

B. Risk for fluid volume deficit

C. Risk for situational fear

D. Risk for disturbed individual coping

• B. Bleeding at the site of catheter introduction is a potential complication leading to fluid volume deficit. Clot displacement is not a nursing diagnosis

44. Which statement would be appropriate for a pulmonary function test?

A. Residual volume is the maximum amount of air that can be expired

B. Vital capacity is the amount of air left after expiration

C. Tidal volume is the amount of air exchanged

D. Pulmonary function may be used to diagnose early stage lung cancer

44. Which statement would be appropriate for a pulmonary function test?

A. Residual volume is the maximum amount of air that can be expired

B. Vital capacity is the amount of air left after expiration

C. Tidal volume is the amount of air exchanged

D. Pulmonary function may be used to diagnose early stage lung cancer

• C. This is the only correct statement.

45. A post-bronchoscopy client develops wheezing, stridor, and becomes cyanotic. Identify the highest priority nursing action.

A. Check the gag reflex to make sure the local anesthetic has worn off

B. Call the client’s physician about the symptoms

C. Assess breath sounds and maintain the airway

D. Encourage the client to cough and deep-breathe to reduce secretions

45. A post-bronchoscopy client develops wheezing, stridor, and becomes cyanotic. Identify the highest priority nursing action.

A. Check the gag reflex to make sure the local anesthetic has worn off

B. Call the client’s physician about the symptoms

C. Assess breath sounds and maintain the airway

D. Encourage the client to cough and deep-breathe to reduce secretions

• C. The client is developing respiratory distress from irritation and swelling of the respiratory mucosa. While all four measures may be appropriate nursing actions, at this time assessing and maintaining the airway have the highest priority.

46. Which instruction is appropriate when providing education to the client who is scheduled for a thoracentesis,?

A. “No eating or drinking will be allowed until your gag reflex returns.”

B. “A feeling of pressure may be experienced during the procedure.”

C. “Peripheral pulses will be assessed frequently following the procedure.”

D. “Bedrest with the head elevated is required for 24 hours after the procedure.”

46. Which instruction is appropriate when providing education to the client who is scheduled for a thoracentesis,?

A. “No eating or drinking will be allowed until your gag reflex returns.”

B. “A feeling of pressure may be experienced during the procedure.”

C. “Peripheral pulses will be assessed frequently following the procedure.”

D. “Bedrest with the head elevated is required for 24 hours after the procedure.”

• B. A feeling of pressure may occur when the physician inserts the large-bore needle into the pleural space. Choices A, C and D are not accurate.

47. A client is complaining of discomfort 1-2 hours after eating with feelings of fullness. How might this best be assessed?

A. Jejunoscopy

B. Laparoscopy

C. Gastroscopy

D. Lower GI series

47. A client is complaining of discomfort 1-2 hours after eating with feelings of fullness. How might this best be assessed?

A. Jejunoscopy

B. Laparoscopy

C. Gastroscopy

D. Lower GI series

• C. Gastroscopy is the direct visualization of the stomach. Another possible assessment would be an upper GI series.

48. The nurse is preparing a client for a colonoscopy scheduled for the next morning. Select the physician order that would require clarification.

A. Administration of a cleansing enema

B. Clear liquid diet the day before the procedure

C. Obtaining a client signature on a consent form

D. A regular breakfast ordered before the procedure

48. The nurse is preparing a client for a colonoscopy scheduled for the next morning. Select the physician order that would require clarification.

A. Administration of a cleansing enema

B. Clear liquid diet the day before the procedure

C. Obtaining a client signature on a consent form

D. A regular breakfast ordered before the procedure

• D. The other choices are appropriate orders prior to a colonoscopy. Since the intestinal system is the focus of this diagnostic procedure, it doesn’t make sense for the client to have regular food prior to the procedure.

49. What would be the best client position for a sigmoidoscopy?

A. Left lateral Sims

B. Right lateral Sims

C. Knee-chest

D. Trendelenburg

49. What would be the best client position for a sigmoidoscopy?

A. Left lateral Sims

B. Right lateral Sims

C. Knee-chest

D. Trendelenburg

• C. This is the correct position.

50. After paracentesis, all of the assessment data is identified. On which should the RN focus the care first?

A. Hypotension and flushed skin

B. Eupnea and increased bowel sounds

C. Peripheral edema and thirst

D. Nausea and fatigue

50. After paracentesis, all of the assessment data is identified. On which should the RN focus the care first?

A. Hypotension and flushed skin

B. Eupnea and increased bowel sounds

C. Peripheral edema and thirst

D. Nausea and fatigue

• A. These are symptoms of hypovolemia with vasodilatation and shock and need immediate attention. While the other symptoms will require attention, they do not place the client in immediate danger.

51. Which statement by the certified nursing assistant indicates understanding of the correct procedure for obtaining a stool specimen for culture and sensitivity?

A. “Apply a thin smear of the stool specimen to a guaiac-impregnated card.”

B. “A special preservative must be placed in the container with the specimen.”

C. “I need to give a small enema to evacuate stool from the bowel for collection.”

D. “A sterile container must be used for specimen collection.”

51. Which statement by the certified nursing assistant indicates understanding of the correct procedure for obtaining a stool specimen for culture and sensitivity?

A. “Apply a thin smear of the stool specimen to a guaiac-impregnated card.”

B. “A special preservative must be placed in the container with the specimen.”

C. “I need to give a small enema to evacuate stool from the bowel for collection.”

D. “A sterile container must be used for specimen collection.”

D. All specimens for culture and sensitivity must be placed in sterile containers to eliminate the possibility of contamination by outside organisms.

52. Which client statement about conscious sedation (moderate sedation) for a colonoscopy indicates that teaching by the nurse has been effective?

A. “After I receive the medicine, I’ll be ‘out like a light’ and will sleep soundly through the whole procedure.”

B. “The medicine I’ll be given for this type of sedation is Stadol (butorphanol), the same medicine I took for pain after my hernia operation.”

C. “I will need to be hospitalized the night before the colonoscopy to be observed for any side effects to a test dose of the conscious sedation medicine.”

D. “This kind of sedation will help me relax, so I can cooperate with the doctor

during the colonoscopy.”

52. Which client statement about conscious sedation (moderate sedation) for a colonoscopy indicates that teaching by the nurse has been effective?

A. “After I receive the medicine, I’ll be ‘out like a light’ and will sleep soundly through the whole procedure.”

B. “The medicine I’ll be given for this type of sedation is Stadol (butorphanol), the same medicine I took for pain after my hernia operation.”

C. “I will need to be hospitalized the night before the colonoscopy to be observed for any side effects to a test dose of the conscious sedation medicine.”

D. “This kind of sedation will help me relax, so I can cooperate with the doctor during the colonoscopy.”

• D. Conscious sedation or “twilight sleep” facilitates decrease in anxiety and promotes cooperation and relaxation. The protective airway reflexes are maintained. Midazolam (Versed) is one agent commonly used for conscious sedation.

NCLEX Review Adult Health ~ 52 Selected Lab & Diagnostic Tests Questions Nursing Considerations &...

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