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A nurse is reinforcing teaching with a client who is to take a fecal occult blood test at home. Which of the following instructions should the nurse include in the teaching?
- A. Apply five drops of developer to each smear.
- B. Use the same part of stool for each sample.
- C. Ensure the sample contains no urine.
- D. Wait 10 min before applying the developing solution.
Correct Answer: C
Rationale: Ensuring the sample is free of urine prevents contamination, which could lead to inaccurate fecal occult blood test results.
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A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?
- A. The client had a hemorrhoidectomy 1 year ago.
- B. The client takes ibuprofen for headaches.
- C. The client consumed citrus juice 3 days before the test.
- D. The client has a history of breast cancer.
Correct Answer: B
Rationale: Ibuprofen, an NSAID, can irritate the gastrointestinal tract and cause minor bleeding, potentially leading to a false-positive fecal occult blood test result.
A nurse is caring for a client who is 6 hr postoperative following a bowel resection. Which of the following findings is the priority for the nurse to report?
- A. The client arouses easily but quickly falls back asleep.
- B. There is 20 mL of dark red drainage from the wound drainage device over the past 4 hr.
- C. There is 60 mL of dark yellow urine from the indwelling urinary catheter over the past 4 hr.
- D. The client reports a pain level of 6 on a scale from 0 to 10 at the incision site.
Correct Answer: A
Rationale: Difficulty staying awake 6 hours post-op suggests potential respiratory depression or neurological issues, a priority to report.
A nurse is reinforcing teaching with a 30-year-old client who is concerned about cervical cancer. Which of the following statements should the nurse make?
- A. Cervical cancer screenings should begin at age 40
- B. Plan to continue cervical cancer screenings for the rest of your life.
- C. You should get a Papanicolaou (Pap) test and human papillomavirus test every 5 years.
- D. If you are immunized against human papillomavirus, you don't need cervical cancer screenings.
Correct Answer: C
Rationale: For a 30-year-old, Pap and HPV testing every 5 years is recommended per current guidelines, making this the correct statement.
A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?
- A. Restrict visitors to family members until the client is able to wear a prosthesis.
- B. Encourage the client to talk with another client who completed rehabilitation for amputation.
- C. Instruct the client to ignore phantom pain sensations.
- D. Suggest that family members bring clothing for the client from home.
- E. Ask the client to describe her feelings about the loss of the affected limb.
Correct Answer: B,D,E
Rationale: Peer support, familiar clothing, and addressing feelings promote psychological adjustment and rehabilitation; restricting visitors or ignoring phantom pain is not therapeutic.
A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?
- A. Aspartate aminotransferase 34 units/L (0 to 34 units/L)
- B. Ammonia 55 mcg/dL (10 to 80 mcg/dL)
- C. Platelets 60,000/mm3 (150,000 to 400,000/mm3)
- D. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)
Correct Answer: C
Rationale: A platelet count of 60,000/mm3 is significantly below the normal range, increasing the risk of bleeding during a liver biopsy, and should be reported to the provider.