Nokea
A nurse is employed as a gastroenterologist's office nurse. When assessing the client, which objective data would provide useful information for diagnosis?
- A. Client verbalizing symptoms of nausea
- B. 22-lb weight loss in 2 months
- C. Client verbalizes chills and fatigue
- D. Client seated and stating pain
Correct Answer: B
Rationale: The best objective data with useful information is the fact that the client has lost 22 pounds in 2 months, indicating significant weight loss in a short period of time. This is data that, with further questioning, could provide further details for diagnosis. A client verbalizing symptoms of nausea and pain constitutes subjective data. Viewing the client's seated posture offers little data.
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The nurse is caring for a client who is scheduled for a percutaneous liver biopsy. Which diagnostic test is obtained prior?
- A. Complete blood count (CBC)
- B. Prothrombin time (PT)
- C. Blood chemistry
- D. Erythrocyte sedimentation rate (ESR)
Correct Answer: B
Rationale: The client must have coagulation studies (PT, aPTT, INR, platelet count) before the procedure because a major complication after a liver biopsy is bleeding. Clients at risk for serious bleeding may receive precautionary vitamin K. A complete blood count and blood chemistry may be completed for baseline values. Typically, an ESR is not associated with the procedure.
The nurse is assessing a client of color for jaundice. In which location(s) would the nurse assess for discoloration? Select all that apply.
- A. The sclera
- B. The gums
- C. The hands
- D. The nails
- E. The hard palate
- F. The conjunctiva
Correct Answer: A,B,E,F
Rationale: In very dark-skinned clients, the nurse inspects the hard palate, gums, conjunctiva, and surrounding tissues for discoloration. If the skin appears jaundiced, the nurse inspects the sclera if it is yellow.
The nurse is reviewing the results of a Hemoccult test with the client. Which question(s) asked by the nurse is important in screening for the potential of a false-positive result? Select all that apply.
- A. Do you take an iron supplement on a daily basis?
- B. Does your diet include a moderate amount of vitamin C?
- C. Are you prescribed regular strength aspirin daily?
- D. Can you tell me the amount of alcohol that you drink on an average week?
- E. When was the last time that you included red meat in your diet?
Correct Answer: C,D,E
Rationale: When obtaining a positive Hemoccult test, the client needs to be screened for a false-positive test result. Substances that may cause a false-positive include red meat, aspirin, and excessive alcohol. Screening for the frequency and amount of these are important. False-negative results are screened in individuals who ingest ascorbic acid and iron supplements.
The nurse is preparing a client for magnetic resonance imaging (MRI) of the abdomen. Which statement by the client would indicate the need to notify the physician?
- A. I haven't had anything to eat or drink since midnight last night.
- B. I really don't like to be in small, enclosed spaces.
- C. I left all my jewelry and my watch at home.
- D. I will practice visualization to remain relaxed during the procedure.
Correct Answer: B
Rationale: An MRI scanner is a narrow, tunnel-like machine that will enclose the client during the test. Clients who are claustrophobic (fear enclosed spaces) may need sedation because it is imperative that they lie still and not panic during the test. Therefore, the nurse should notify the physician about the client's statement. Typically, the client is NPO for 6 to 8 hours before the test, and he or she must remove any metal objects, credit cards, jewelry, and watch before the test. Visualization will assist the client in relaxing during the procedure.
The nurse is accompanying the client to the diagnostic imaging unit for a magnetic resonance imaging (MRI). Which action by the nurse is most important prior to the test?
- A. Instruct the client that the scanner makes loud clanging.
- B. Calculate drop per minute for intravenous fluids and infuse by gravity.
- C. Support client, if nervous, by words of encouragement.
- D. Ensure that the client does not ingest fluids in the waiting area.
Correct Answer: B
Rationale: It is most important that the nurse calculate the drip rate of the intravenous fluids because the client will not be able to have an electrical or mechanical pump operating during the MRI. The MRI electrical charges during the test can affect the pump. It is also important to advise the client of the loud noises and offer support to the client. Water is typically not available in the waiting area prior to testing.