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1) The nurse would call the primary care provider immediately for which laboratory
result?
1. Hgb = 16 g/dL for a male client
2. Hct = 22% for a female client
3. WBC = 9 × 103/mL3
4. Platelets = 300 × 103/mL3
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Answer: 2. Rationale: Option 2 is very low and can lead to death. The
client's red blood cells participate in oxygenation. Options 1, 3, and 4 are
within normal range and should not be reported to the primary care
provider. Cognitive Level: Applying. Client Need: Physiological Integrity.
Nursing Process: Implementation. Learning Outcome: 34-3.
7) The nurse practitioner requests a laboratory blood test to determine how well a
client has controlled her diabetes during the past 3 months. Which blood test will
provide this information?
,1. Fasting blood glucose
2. Capillary blood specimen
3. Glycosylated hemoglobin
4. GGT (gamma-glutamyl transferase)
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Answer: 3. Rationale: A glycosylated hemoglobin will indicate the glucose
levels for a period of time, which is indicated by the nurse practitioner.
Options 1 and 2 will provide information about the current blood glucose,
not the past history. Option 4 is used to assess for liver disease. Cognitive
Level: Remembering. Client Need: Physiological
Integrity. Nursing Process: Planning. Learning Outcome: 34-2
9) Which focus is the nurse most likely to teach for a client with a flaccid bladder?
1. Habit training: Attempt voiding at specific time periods.
2. Bladder training: Delay voiding according to a preschedule timetable.
3. Credé's maneuver: Apply gentle manual pressure to the lower abdomen.
4. Kegel exercises: Contract the pelvic muscles.
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Answer: 3. Rationale: Because the bladder muscles will not contract to
increase the intrabladder pressure to promote urination, the process is
initiated manually. Options 1, 2, and 4: To promote continence, bladder
contractions are required for habit training, bladder training, and increasing
the tone of the pelvic muscles. Cognitive Level: Applying. Client Need:
Physiological Integrity. Nursing Process: Implementation. Learning
Outcome: 48-9.
9) A primary care provider is going to perform a thoracentesis. The nurse's role will
include which action?
1. Place the client supine in the Trendelenburg position.
2. Position the client in a seated position with elbows on the overbed table.
, 3. Instruct the UAP to measure vital signs.
4. Administer an opioid analgesic
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Answer: 2. Rationale: The puncture site is usually on the posterior chest. The
client should be positioned leaning forward. This will allow the ribs to
separate for exposure of the site. Option 1 is incorrect. The client should not
be placed in the Trendelenburg position because the site would not be
exposed. Option 3 is incorrect since changes in vital signs do not routinely
occur with this procedure. Option 4 is incorrect. The client does not need
to be medicated for pain with this procedure. Cognitive Level: Analyzing.
Client Need: Physiological Integrity. Nursing Process: Planning. Learning
Outcome: 34-10
3) The client has a urinary health problem. Which procedure is performed using
indirect visualization?
1. Intravenous pyelography (IVP)
2. Kidneys, ureter, bladder (KUB)
3. Retrograde pyelography
4. Cystoscopy
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Answer: 2. Rationale: A KUB is an x-ray of the kidneys, ureters, and bladder.
This does not require direct visualization. Option 1 is an IVP, an intravenous
pyelogram, which requires the injection of a contrast media. Option 3 is a
retrograde pyelography, which requires the injection of a contrast media.
Option 4 is a cystoscopy, which uses a lighted instrument (cystoscope)
inserted through the urethra, resulting in direct visualization. Cognitive
Level: Remembering. Client Need: Physiological Integrity. Nursing Process:
Assessment. Learning Outcome: 34-8