Question 1

A client with a suspected case of tuberculosis (TB) asks the nurse what test will confirm the diagnosis. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: Sputum smear/culture (and/or nucleic acid amplification testing) directly detects the organism, making it confirmatory rather than just suggestive. A chest X-ray can support suspicion but is not specific and cannot prove TB. The tuberculin skin test indicates exposure/latent infection and can be false-positive or false-negative, so it does not confirm active disease; urine culture is not the standard confirmatory test for pulmonary TB.

Question 2

A toddler with suspected cystic fibrosis is admitted for testing. The nurse explains that the diagnostic criterion for chloride levels is?

Accepted Answer

Answer reason: The sweat chloride test is the standard diagnostic test for cystic fibrosis, reflecting defective CFTR chloride transport that increases chloride concentration in sweat. A value at or above 60 mmol/L on a properly collected sweat test is considered diagnostic in symptomatic children or with supportive findings. Values in the 40–60 mmol/L range are typically considered intermediate/borderline and require repeat testing and/or additional evaluation (e.g., CFTR genetic testing). Very low values (e.g.,

Question 3

Which test is most commonly used to determine the area of myocardial damage during or after a myocardial infarction (MI)?

Accepted Answer

Answer reason: An MI produces characteristic ECG changes (ST-segment elevation/depression, T-wave inversion, and pathologic Q waves) that help localize the affected myocardial region by correlating specific lead patterns with coronary territories. It is the most common rapid bedside test available during and after suspected infarction to map the area involved and monitor evolution over time. Cardiac enzymes confirm myocardial necrosis and help quantify infarct size/ongoing injury, but they do not localize the anatomic area of damage. Echocardiography can identify wall-motion abnormalities and complications, yet ECG remains the most commonly used initial tool for determining infarct location.

Question 4

A client has copious secretions. X-ray results indicate tuberculosis (TB). The nurse anticipates that the client will most likely have which procedure ordered?

Accepted Answer

Answer reason: This procedure allows collection of samples (e.g., bronchial washings) and evaluation of airway obstruction or other causes of excessive secretions. A repeat chest x-ray does not address immediate secretion burden or provide definitive microbiologic sampling. ABGs assess gas exchange but do not diagnose TB or manage/copiously evaluate airway secretions, and tracheostomy is reserved for specific airway/ventilation indications rather than routine TB evaluation.

Question 5

A client has been diagnosed with epiglottitis. The nurse recognizes that the client was diagnosed based on which of the following?

Accepted Answer

Answer reason: This approach confirms the cause of upper-airway obstruction and guides urgent airway management decisions. A lateral neck X-ray can support suspicion (e.g., “thumb sign”) but is less definitive and should not delay airway stabilization. History and symptoms are important for recognition (fever, drooling, tripod positioning, muffled voice/stridor) but are not confirmatory diagnostic criteria on their own.

Question 6

A client presents with weight gain, intolerance to cold, constipation, and lethargy. Which test should the nurse expect to be ordered?

Accepted Answer

Answer reason: The most appropriate initial evaluation is thyroid function testing to assess circulating thyroxine and pituitary response. Measuring TSH helps distinguish primary thyroid failure (typically high TSH with low T4) from central causes (low/normal TSH with low T4). Hemoglobin A1C evaluates chronic glycemia, and 24-hour urine free cortisol screens for hypercortisolism, neither matching the symptom cluster as directly as thyroid studies.

Question 7

A client is diagnosed with prostate cancer. The physician is most likely to order which test to monitor the client's progress?

Accepted Answer

Answer reason: PSA is produced by prostate tissue and is the standard lab test trended to monitor prostate cancer burden after therapy (e.g., surgery, radiation, androgen-deprivation), with rising values suggesting persistent or recurrent disease. Creatinine and potassium primarily assess renal function and electrolyte status rather than cancer activity. A CBC can reflect anemia or infection and may be relevant during chemotherapy, but it is not the primary disease-specific marker for monitoring prostate cancer.

Question 8

The experienced nurse is instructing the new nurse. The experienced nurse explains that the definitive diagnosis of PUD involves which test?

Accepted Answer

Answer reason: Endoscopy confirms an ulcer, characterizes its location and severity, and allows biopsy to rule out malignancy and assess for H. pylori when appropriate. Noninvasive tests like the urea breath test identify H. pylori infection but do not directly confirm the presence of an ulcer or exclude cancer. Imaging such as barium studies can suggest ulceration but is less accurate and does not permit biopsy.

Question 9

The child with a sore throat is hospitalized with a tentative diagnosis of epiglottitis. Which diagnostic test result should the nurse plan to review to confirm the diagnosis?

Accepted Answer

Answer reason: A lateral neck radiograph can show an enlarged epiglottis (classic “thumbprint” appearance), which is a direct finding consistent with this diagnosis. Blood or throat cultures may help identify the organism but do not confirm the presence of epiglottic swelling and can delay or risk agitation in an unstable child. A CBC may show nonspecific leukocytosis and is not diagnostic for epiglottitis, so it is less useful for confirmation than targeted imaging.

Question 10

What is the first intervention for the nurse to implement for a client experiencing myocardial infarction (MI)?

Accepted Answer

Answer reason: The priority in suspected MI is rapid identification of ischemia/infarction to guide time-sensitive reperfusion and medication decisions. A 12-lead ECG is the key immediate diagnostic test because it distinguishes STEMI from NSTEMI/unstable angina and drives urgent actions (eg, cath lab activation) without delay. Oxygen is no longer routine unless hypoxemia or respiratory distress is present, and giving it first can waste critical minutes. Nitroglycerin and morphine may relieve pain/ischemia but require assessment for contraindications (eg, hypotension, RV infarct, recent PDE-5 inhibitor use) and should not precede obtaining the ECG.

Question 11

Which diagnostic study can determine when cellular metabolism becomes anaerobic and when pH decreases?

Accepted Answer

Answer reason: This makes it the most appropriate test to identify when pH is decreasing due to systemic hypoperfusion or respiratory failure. A CBC can suggest infection or anemia but cannot determine acid-base balance. ECG and lung scan evaluate cardiac electrical activity and pulmonary perfusion/ventilation issues, respectively, but neither directly quantifies pH or acid-base derangements.

Question 12

If a client had irritable bowel syndrome, which diagnostic test would determine if the diagnosis is Crohn’s disease or ulcerative colitis?

Accepted Answer

Answer reason: This test can identify continuous mucosal inflammation starting at the rectum typical of ulcerative colitis versus skip lesions, cobblestoning, and possible ileal involvement suggestive of Crohn’s disease, and biopsy helps confirm chronic inflammatory changes and exclude other causes. CT can show complications (e.g., abscess, fistula) but is not the primary test to distinguish these diagnoses. Abdominal X-ray and barium swallow do not adequately evaluate colonic mucosa or provide tissue for diagnosis.

Question 13

The client is exhibiting symptoms indicative of pneumonia. The nurse anticipates that which diagnostic test will be orders to confirm the diagnosis?

Accepted Answer

Answer reason: A chest radiograph is the standard first-line diagnostic test because it can directly demonstrate lobar or patchy infiltrates and help assess extent and complications (e.g., effusion). ABGs evaluate oxygenation/ventilation severity but do not establish the presence of an infectious infiltrate. Blood and sputum cultures help identify the organism and guide antibiotic selection, but they are adjuncts and are not required to confirm the diagnosis.

Question 14

Which statement about transposition of the great arteries is correct?

Accepted Answer

Answer reason: Prenatal screening can identify major congenital heart defects using fetal echocardiography, which can visualize abnormal great-vessel connections before birth. This is particularly important in transposition of the great arteries because early recognition allows delivery planning at a center prepared for prostaglandin therapy and urgent intervention after birth. An ECG does not consistently show arrhythmias, and a chest X-ray may suggest findings (e.g., cardiomegaly/"egg-on-a-string") but cannot define the anatomic defect accurately compared with echocardiography. Heart failure can occur in TGA, especially when there is inadequate mixing or associated lesions, so it is a potential complication.

Question 15

A Mantoux test is ordered for a 6-year-old child. What is the most important action by the nurse?

Accepted Answer

Answer reason: The Mantoux (PPD) skin test is a delayed-type (type IV) hypersensitivity reaction that requires time for induration to develop. The nurse must ensure the test is read at the correct interval (48–72 hours) to avoid false-negative or unreliable interpretation. Reading within 24 hours is too early because induration may not yet be present. Using an upper-leg muscle is incorrect because the test is administered intradermally (typically on the forearm), and the site should not be massaged because it can alter local tissue response.

Question 16

The nurse is preparing a child for testing for a foreign body aspiration. The nurse explains to the child’s parents that the best diagnostic tool for diagnosis of foreign body aspiration is?

Accepted Answer

Answer reason: Definitive diagnosis of suspected foreign body aspiration requires direct visualization of the airway, because many aspirated objects are radiolucent and may not appear on standard imaging. Bronchoscopy allows the clinician to inspect the tracheobronchial tree and confirm the presence and location of the object. It is also both diagnostic and therapeutic, enabling removal during the same procedure, which reduces ongoing obstruction and complications (air trapping, atelectasis, pneumonia). Chest X-ray or fluoroscopy may show indirect signs (unilateral hyperinflation, mediastinal shift) but cannot reliably confirm or exclude aspiration.

Question 17

The nurse is preparing a client for a lumbar puncture. Which is the appropriate position for the client?

Accepted Answer

Answer reason: Lumbar puncture requires maximal flexion of the spine to widen the intervertebral spaces and improve access to the subarachnoid space while minimizing traumatic needle passes. The lateral recumbent “fetal” position flexes the lumbar spine and stabilizes the client for accurate needle placement. A generic side-lying position may not provide enough flexion, increasing difficulty and risk of multiple attempts. Semi-Fowler’s reduces spinal flexion, and prone positioning is not the standard positioning for routine diagnostic lumbar puncture.

Question 18

The nurse cares for a client suspected of having hypothyroidism. Which test can the nurse expect the physician to order?

Accepted Answer

Answer reason: Hypothyroidism is primarily evaluated by assessing thyroid hormone output and pituitary feedback. A low free T4 with an elevated TSH is classic for primary hypothyroidism, while low/normal TSH with low T4 suggests central (pituitary/hypothalamic) causes. These labs directly confirm the diagnosis and help localize the level of dysfunction. CBC, electrolytes, and liver tests may show nonspecific associated abnormalities but do not establish thyroid status and are not the key diagnostic tests.

Question 19

The nurse is caring for a pregnant client who is suspected of having cardiovascular disease. Select the diagnostic test that may be performed to determine the extent of cardiovascular disease during pregnancy?

Accepted Answer

Answer reason: This test assesses chamber size, ventricular function, valve disease, and estimates pressures, which directly helps determine severity and extent of many maternal cardiac conditions. A chest X-ray uses radiation and is less informative for defining cardiac function, while stress testing can impose physiologic strain and is not first-line for defining disease extent in pregnancy. Cardiac catheterization is invasive and involves radiation/contrast, so it is generally reserved for urgent, specific indications rather than routine assessment.

Question 20

A nurse suspects that an infant may have transposition of the great vessels (TGV) based on her assessment findings. Which diagnostic test would be performed first to detect this problem?

Accepted Answer

Answer reason: This study can confirm transposition by showing the abnormal connections of the great arteries and assessing associated shunts (eg, ASD/VSD/PDA) and ventricular function. Cardiac catheterization is invasive and typically reserved for therapeutic interventions or when noninvasive imaging is inconclusive. Chest X-ray may show nonspecific signs (eg, cardiomegaly or characteristic silhouette) but cannot definitively diagnose the structural defect, and blood cultures are irrelevant to detecting this condition.

Question 21

A client is exhibiting Kussmaul’s respirations, abdominal discomfort, and lethargy. If random serum glucose is 325 mg/dl, which additional test should be conducted?

Accepted Answer

Answer reason: Confirming ketosis is essential to differentiate DKA from other causes of hyperglycemia and altered mentation and to guide urgency and type of treatment (e.g., insulin and fluid resuscitation with electrolyte management). Checking ketones directly assesses the core pathophysiology responsible for the deep, rapid breathing pattern. BUN/creatinine may be abnormal from dehydration but does not confirm the diagnosis, and CBC or liver enzymes are not the key targeted tests for this presentation.

Question 22

A urine culture has been ordered for a male client. The nurse instructs the client to?

Accepted Answer

Answer reason: Urine culture accuracy depends on minimizing contamination from urethral and perineal flora. A clean-catch midstream specimen flushes initial contaminants away and then collects urine that more closely represents bladder contents, while using a sterile container further reduces false-positive growth. Collecting first-void urine into a “clean” container or transferring urine from a urinal increases contamination risk and can invalidate culture results. Perineal cleansing is helpful, but the key instruction for culture collection is the midstream sterile clean-catch technique.

Question 23

What is the most important information for the nurse to teach a client about hypersensitivity skin test results?

Accepted Answer

Answer reason: Hypersensitivity skin testing is time-sensitive because the presence and size of induration/erythema must be measured within a specific window to be interpreted accurately. If the client returns too early or too late, the reaction may be missed or mismeasured, leading to false-negative or inaccurate results and inappropriate follow-up care. Teaching about protecting the site is secondary to ensuring valid diagnostic interpretation. Lotions and excessive washing can interfere with local skin assessment, but incorrect timing is the highest-risk error because it invalidates the entire test outcome.

Question 24

The client has a hearing loss from a possible acoustic neuroma. The nurse should prepare the client for which diagnostic test to confirm the presence of a tumor?

Accepted Answer

Answer reason: It provides detailed soft-tissue contrast and can identify small tumors that would not be detected by middle-ear function tests. Tympanometry evaluates tympanic membrane compliance and middle-ear pressure, which does not confirm a retrocochlear tumor. An arteriogram is not a primary diagnostic test for this condition, and biopsy of the auditory canal is inappropriate because the tumor is not in the external canal and biopsy risks injury without diagnostic benefit.

Question 25

The child is being seen in the clinic after bumping into objects, stating seeing halos around objects, and sometimes having diplopia. A referral is made for a tonometry test. The nurse should explain to the parents that a tonometry test is used to test for which problem?

Accepted Answer

Answer reason: The child’s symptoms (bumping into objects suggesting peripheral vision loss and seeing halos) are classic for increased intraocular pressure and optic nerve compromise. Diplopia can occur with visual disturbance but does not change that the purpose of tonometry is pressure assessment. Cataracts are assessed by lens opacity on exam, and strabismus/amblyopia are alignment/visual acuity issues rather than pressure-related disorders.

Question 26

The toilet-trained child presents with incontinence, strong-smelling urine, frequency, and urgency. What laboratory specimen should the nurse collect first?

Accepted Answer

Answer reason: Collecting urine early also helps ensure the sample is obtained before antibiotics or hydration changes can alter results. Blood tests like CBC or serum creatinine are not the initial specimen for an uncomplicated lower-tract presentation and do not confirm a urinary source. Blood culture is reserved for toxic appearance, sepsis concern, or complicated infection rather than routine first-line testing in a stable toilet-trained child.

Question 27

The nurse is aware that in addition to the client’s platelet count, the best test to confirm the diagnosis of essential thrombocytopenia would be?

Accepted Answer

Answer reason: In thrombocytopenic states, bleeding time is typically prolonged, supporting that the clinical problem is platelet-related rather than a coagulation-factor deficiency. PT/INR assesses the extrinsic/common coagulation pathways and is usually normal in isolated platelet problems, so it is less useful for confirming a platelet-based diagnosis. WBC count and IgG levels do not directly evaluate platelet-mediated hemostasis and therefore are not confirmatory tests for this condition.

Question 28

The nurse determines that teaching was successful when a client with a negative human immunodeficiency virus (HIV) antibody test makes which statement?

Accepted Answer

Answer reason: ” A negative HIV antibody test means antibodies were not detected, which can occur either because the person is truly uninfected or because testing occurred during the window period before seroconversion. This statement correctly interprets what the specific test measures (antibody response) without overclaiming infection status. Saying the client is not infected is unsafe because early infection may still yield a negative antibody result. Claiming immunity or the presence of antibodies directly contradicts a negative antibody test result and reflects misunderstanding of the test.

Question 29

A client is diagnosed with Ewing’s sarcoma. The nurse anticipates that which test would be most appropriate in determining the extent of metastasis?

Accepted Answer

Answer reason: PET imaging highlights areas of increased glucose uptake and is therefore well suited to evaluating the overall extent of metastatic disease in aggressive sarcomas. In contrast, MRI is best for defining local tumor extent and soft-tissue involvement, and CT is typically targeted to specific regions rather than providing functional whole-body screening. A bone scan detects osteoblastic activity and can miss purely marrow-based or early metastatic lesions compared with functional PET assessment.

Question 30

The nurse is caring for a client in the intensive care unit with acute cardiopulmonary problems. The client is receiving mechanical ventilation for cardiopulmonary support. How often is a chest x-ray indicated for clients receiving mechanical ventilation?

Accepted Answer

Answer reason: Mechanically ventilated ICU clients are at ongoing risk for complications such as atelectasis, pneumonia, pulmonary edema, and malposition of tubes/lines, so routine monitoring with imaging is commonly ordered at a regular interval. Daily chest radiographs help trend lung expansion and identify evolving pathology early enough to adjust ventilator settings and therapies. Hourly or twice-daily imaging is excessive and increases radiation exposure without typical added clinical benefit unless there is acute deterioration or a new procedure (e.g., line placement). Weekly imaging is too infrequent to safely monitor common rapid changes in critically ill ventilated patients.

Question 31

A nurse is aware that family members of a client diagnosed with tuberculosis may have been exposed to the disease. The nurse explains that a tuberculin skin test should be performed on each family member and may indicate?

Accepted Answer

Answer reason: The tuberculin skin test (PPD) measures a delayed-type hypersensitivity response to mycobacterial antigens, which reflects prior sensitization rather than current disease activity. A positive result indicates TB infection (latent or prior exposure) has occurred, but it cannot distinguish latent infection from active tuberculosis. It also does not provide information about the anatomic burden or “extent” of disease, which requires clinical evaluation and imaging/microbiology. Because the immune response can persist for years after exposure or infection, the result most appropriately indicates infection/exposure at some point in time.

Question 32

The nurse is caring for an intubated client who has copious, brown-tinged secretions. What is the most appropriate intervention by the nurse?

Accepted Answer

Answer reason: An intubated client with copious, discolored secretions may need a lower-airway specimen to evaluate infection and guide antibiotic therapy. A sputum trap attached to the suction system allows collection of a sterile tracheal specimen without contaminating it with oral flora, improving diagnostic accuracy. Routine saline instillation is generally avoided because it can worsen hypoxemia, increase coughing/bronchospasm, and does not reliably improve secretion clearance. Swabbing with a culturette is not an appropriate method to obtain a representative lower-respiratory specimen through an endotracheal tube, and mucolytics require a provider order and do not address the immediate need for appropriate diagnostic sampling.

Question 33

The nurse obtains a client’s stool sample for occult blood. Which of the following diets can cause a false-positive test result?

Accepted Answer

Answer reason: Red meat contributes heme, which has pseudo-peroxidase activity, and certain vegetables such as horseradish and turnips contain peroxidase enzymes that can oxidize the test reagent. This combination therefore increases the risk of a false-positive result when the specimen is collected soon after ingestion. By contrast, items like dairy, potatoes, and juice are not typical causes of guaiac false-positives (vitamin C is more associated with false-negatives due to inhibition).

Question 34

The nurse is caring for a client who has been admitted with a suspected diagnosis of diabetes insipidus (DI). The nurse can expect which of the following tests to confirm the diagnosis?

Accepted Answer

Answer reason: The water (fluid) deprivation test assesses whether urine osmolality/specific gravity appropriately rises with dehydration; failure to concentrate supports DI, and response to desmopressin helps distinguish central from nephrogenic DI. Blood or urine glucose testing is aimed at diabetes mellitus, not DI, and ketone testing is used to evaluate ketoacidosis/starvation ketosis rather than a water-balance disorder. Therefore the diagnostic study expected to confirm suspected DI is the deprivation test performed with close monitoring for dehydration and hypernatremia.

Question 35

The nurse is admitting the client for a colonoscopy. Which information, if found in the client’s medical record, should the nurse consider as the primary reason for this client’s colonoscopy?

Accepted Answer

Answer reason: A prior history of polyps is a strong, common indication for surveillance colonoscopy because of the higher likelihood of recurrence and malignant transformation risk. Chronic constipation alone is usually evaluated first with less invasive assessment unless alarm features are present. A urostomy history does not directly indicate colon evaluation, and a hemoglobin of 10 g/dL is nonspecific and would require context (e.g., occult GI bleeding) rather than being the most direct primary indication listed.

Question 36

The nurse is teaching the client who is to undergo diagnostic testing for possible gastric cancer. Teaching the client about which specific diagnostic test would be most helpful?

Accepted Answer

Answer reason: Upper endoscopy (EGD) inspects the esophagus, stomach, and duodenum and permits biopsy of suspicious lesions, which is essential for confirming malignancy and guiding staging/management. Bronchoscopy evaluates the airways and would not assess gastric mucosa. A MUGA scan assesses cardiac ejection fraction (often before cardiotoxic chemotherapy) and is not a primary diagnostic test for detecting gastric cancer.

Question 37

The nurse has just admitted a client to the unit with a diagnosis of suspected peptic ulcer. The nurse anticipates that the doctor will order which test?

Accepted Answer

Answer reason: It also allows biopsy and testing for H. pylori, which guides definitive treatment and reduces recurrence risk. Plain abdominal x-ray and CT do not reliably detect uncomplicated ulcers and are mainly helpful for complications (e.g., perforation or alternative diagnoses). A barium study is less sensitive and does not allow biopsy or immediate therapeutic intervention if bleeding is found.

Question 38

A client is admitted with a possible diagnosis of rheumatoid arthritis (RA). Which of the following screening tests should the nurse expect to be ordered?

Accepted Answer

Answer reason: RF is a traditional screening test used in suspected RA and supports the diagnosis when positive in the appropriate clinical context. ESR is a nonspecific marker of inflammation that may be elevated in many conditions and is more useful for assessing inflammatory activity than for screening specificity. ANA is more strongly associated with systemic lupus erythematosus and other connective-tissue diseases, and CBC is supportive for complications (e.g., anemia of chronic disease) rather than a primary screening test for RA.

Question 39

A client has a positive Mantoux test, and a chest X-ray is ordered. The client asks the nurse the reason for the X-ray. What is the best response by the nurse?

Accepted Answer

Answer reason: A chest X-ray is obtained to evaluate for radiographic evidence of active TB and to assess the presence, location, and severity of pulmonary involvement. This helps guide next steps such as sputum testing, isolation decisions, and treatment planning based on suspected disease burden. A common misconception is that the X-ray “confirms” TB; definitive diagnosis relies on microbiologic testing, while imaging supports assessment and risk stratification.

Question 40

A client with a suspected diagnosis of lung cancer tells the nurse the doctor is scheduling tests to confirm the diagnosis. The nurse understands that the definitive diagnosis will be determined by?

Accepted Answer

Answer reason: Definitive cancer diagnosis requires histologic confirmation of malignant cells from tissue. A surgical biopsy provides an adequate specimen for pathology to confirm malignancy and often allows tumor typing and staging-related details. Imaging tests such as chest X-ray and CT can identify suspicious masses and guide further evaluation but cannot confirm cancer on their own. Bronchoscopy may visualize and sample lesions, but the definitive confirmation still depends on tissue pathology, which is most reliably obtained via biopsy.

Question 41

A neonate is suspected of having esophageal atresia. The nurse is aware that a definitive diagnostic evaluation would include which factor?

Accepted Answer

Answer reason: Inability to pass an orogastric/nasogastric catheter into the stomach, with the tube meeting resistance or coiling, directly supports the diagnosis and prompts confirmatory imaging while avoiding oral feeds. The other findings are indirect and can occur with many neonatal conditions (e.g., respiratory distress causing altered breath sounds) and do not confirm anatomic interruption of the esophagus. Assessing feeding tolerance is unsafe as a diagnostic strategy because it can worsen aspiration and respiratory compromise in this condition.

Question 42

A client is sent for a computerized tomography (CT) scan with dye injection. The nurse explains to the client?

Accepted Answer

Answer reason: IV iodinated contrast commonly causes a transient sensation of warmth and flushing (sometimes a metallic taste or nausea), which is expected and self-limited. Teaching this normal effect helps reduce anxiety and supports safe completion of the diagnostic test. A CT with contrast is typically brief rather than hours long, and general anesthesia/unconsciousness is not expected. NPO requirements vary by facility/protocol and are not reliably 12 hours for all CT contrast studies, making that statement less accurate as general teaching.

Question 43

The nurse is caring for a client who had a pacemaker inserted over 20 years ago. He has been admitted to the cardiac care unit with possible bacterial endocarditis. The nurse would expect which test to confirm the diagnosis of bacterial endocarditis?

Accepted Answer

Answer reason: Multiple sets from separate venipuncture sites identify the causative organism and guide targeted antimicrobial therapy, which is central to diagnosis and management. Electrolytes and PT may be monitored during illness or treatment but do not establish the diagnosis. VDRL screens for syphilis and is unrelated to confirming infective endocarditis.

Question 44

The nurse is caring for a 60-year-old male client suspected of having coronary artery disease. The physician has ordered a noninvasive diagnostic test to evaluate cardiac changes. The nurse prepares the client for which test?

Accepted Answer

Answer reason: MRI can evaluate cardiac structure and function (e.g., myocardial changes, ventricular function) without catheter insertion or needle aspiration, fitting the order for a noninvasive evaluation. Cardiac catheterization is invasive because it requires vascular access and intracardiac/vascular instrumentation (often with contrast). Cardiac biopsy and pericardiocentesis are invasive procedures performed for specific indications (myocardial tissue diagnosis or pericardial fluid removal), not as routine noninvasive evaluation for suspected coronary artery disease.

Question 45

The nurse is providing discharge instructions for a client treated for acute pyelonephritis. What is the most important information for the nurse to include?

Accepted Answer

Answer reason: Acute pyelonephritis can persist or relapse if the causative organism is not fully eradicated, so confirming microbiologic clearance is a key safety step after treatment. Follow-up urine cultures help detect ongoing infection, resistant organisms, or recurrence early enough to prevent renal complications and sepsis. Stopping antibiotics when symptoms improve is unsafe because symptoms often resolve before the infection is fully treated. Advice about dairy avoidance is not a universal discharge priority and depends on the specific antibiotic, whereas follow-up testing directly reduces risk of complications.

Question 46

The nurse is caring for the client experiencing a possible hospital-acquired bladder infection. Which nursing action should the nurse perform first?

Accepted Answer

Answer reason: Collecting cultures before starting antimicrobial therapy is a core principle to avoid altering results and missing the causative organism. A urine culture with sensitivity identifies the pathogen and guides selection of the most effective antibiotic, which is especially important for hospital-acquired infections with higher resistance risk. Giving antibiotics first can sterilize the urine and lead to a false-negative culture or incomplete susceptibility data. Education on hygiene and preparing for catheter removal are important prevention/management steps, but they do not take priority over obtaining accurate diagnostic data when infection is suspected.

Question 47

A client who is being evaluated for myocardial infarction (MI) asks the nurse which diagnostic tool is most commonly used to determine the location of myocardial damage. The best response by the nurse is?

Accepted Answer

Answer reason: The core principle is that myocardial injury produces predictable electrical changes that can be mapped to specific myocardial regions using lead distributions. An ECG is the most commonly used, rapid bedside test that localizes infarct territory (e.g., inferior, anterior, lateral) by identifying ST-segment elevation/depression and Q-wave patterns in corresponding leads. Cardiac enzymes confirm myocardial necrosis but do not localize which wall is affected. Echocardiography can show regional wall-motion abnormalities, but it is not the most commonly used tool for determining MI location in initial evaluation compared with the ECG.

Question 48

A nurse is preparing a client with suspected lumbar herniated nucleus pulposus for magnetic resonance imaging (MRI). The most important action by the nurse would be?

Accepted Answer

Answer reason: MRI requires the patient to remain very still in an enclosed, noisy environment, and anxiety/claustrophobia is a common cause of motion artifact and incomplete studies. Preparing the client with relaxation strategies (e.g., breathing, guided imagery, coping plan for staying still) directly improves test quality and safety without introducing unnecessary interventions. Iodine allergy screening is associated with iodinated contrast used in CT/myelography, not standard MRI. Marking distal pulses is a key preoperative/vascular assessment step and is not the priority for an MRI preparation.

Question 49

A nurse is preparing the family of a client with Kawasaki disease for discharge. What is the most appropriate information for the nurse to include?

Accepted Answer

Answer reason: Kawasaki disease can cause coronary artery aneurysms and myocarditis, so ongoing cardiac surveillance is essential after discharge. Serial echocardiograms are the standard noninvasive way to assess coronary artery involvement and ventricular function over time. Stopping aspirin is unsafe because antiplatelet therapy is commonly continued to reduce thrombosis risk when coronary changes are possible. Immunizations are typically delayed for months after IVIG, not just 2 weeks, making that teaching inaccurate.

Question 50

A pediatrician suspects that a child has pinworms and instructs the nurse to assess the child for their presence. The nurse determines that which method is most reliable for assessing for pinworms?

Accepted Answer

Answer reason: The cellophane tape test captures these eggs directly from the anal margin, especially when performed in the morning before bathing or toileting, making it the most reliable assessment method. Symptoms like nocturnal perianal itching and restlessness are suggestive but are not definitive and can overlap with other causes of pruritus. Blood and stool cultures do not reliably detect this helminth infection because eggs are usually not present in stool and culture techniques are not used for pinworms.

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