Question 1

Which information should a nurse provide to the parents of child undergoing testing for the diagnosis of muscular dystrophy?

Accepted Answer

Answer reason: Muscular dystrophy is commonly evaluated with diagnostic studies such as muscle biopsy and electromyography/nerve conduction studies, which involve needle insertion and can be uncomfortable. Teaching should prepare parents for expected steps that reduce pain and anxiety, including the use of local anesthetic for procedures like a biopsy. Covering genitals with a lead apron refers to radiation protection for imaging and is not central to confirming muscular dystrophy. Attaching electrodes to the scalp is consistent with EEG for seizure evaluation, and inserting a fiber-optic scope into a joint describes arthroscopy, neither of which are typical confirmatory tests for muscular dystrophy.

Question 2

The client diagnosed with chronic atrial fibrillation has experienced a transient TIA. Which discharge instruction should the nurse implement?

Accepted Answer

Answer reason: Atrial fibrillation increases the risk of atrial thrombus formation and embolic stroke/TIA, so long-term anticoagulation is commonly prescribed for secondary prevention. Warfarin therapy requires routine INR monitoring to confirm therapeutic anticoagulation while minimizing bleeding risk. This instruction directly targets prevention of recurrent cerebrovascular events and detection of under- or over-anticoagulation. A common pitfall is altering vitamin K intake, which can reduce warfarin effectiveness and raise stroke risk. Pulse checks and nitroglycerin storage are not the key discharge focus for preventing embolic events after TIA in chronic atrial fibrillation.

Question 3

A client presents to the emergency department with complaint of severe indigestion. The physician orders diagnostic tests to confirm cholecystitis. The nurse anticipates that the physician will order which test?

Accepted Answer

Answer reason: First-line evaluation for suspected cholecystitis is imaging that can rapidly assess gallstones and gallbladder inflammation at the bedside without radiation. Ultrasound directly visualizes gallstones, gallbladder wall thickening, pericholecystic fluid, and a sonographic Murphy sign, making it the most appropriate confirmatory test in typical presentations. CT can miss small stones and is generally reserved for complications or alternative diagnoses. Barium swallow evaluates esophageal disorders, and colonoscopy evaluates the colon, so neither addresses suspected gallbladder pathology.

Question 4

Two days after undergoing a left thoracotomy, a client’s temperature reaches 102°F (38.9°C). The nurse notifies the physician, who orders two sets of blood cultures. Which amount of blood would the nurse obtain for cultures?

Accepted Answer

Answer reason: Standard adult practice is to draw about 8–10 mL per culture bottle, so a 10 mL draw aligns with obtaining a diagnostically useful specimen for each set. Smaller volumes like 2 mL or 5 mL reduce yield and increase the chance of false-negative results. While larger volumes can be used in some protocols, 20 mL is not the typical single-bottle target volume and may exceed what is needed per bottle for routine adult cultures.

Question 5

The nurse is teaching the client who is scheduled For an outpatient EEG. Which instruction should the nurse include?

Accepted Answer

Answer reason: An EEG requires accurate scalp electrode contact and avoidance of external interference with lead placement. Removing metal hairpins and similar accessories helps ensure unobstructed positioning of electrodes and reduces artifact risk from contact or pressure points. Routine EEG preparation typically allows normal meals (or may even encourage eating to avoid hypoglycemia-related changes), so fasting is not a standard instruction. Scalp hair is not shaved for electrode placement, and pre-test glucose draws are not part of standard outpatient EEG preparation.

Question 6

The nurse is planning care for the client, who is scheduled for an IVP. Which intervention should the nurse plan to implement?

Accepted Answer

Answer reason: IVP uses iodinated contrast, and a transient feeling of warmth or flushing is a common, expected sensation that clients should be taught to reduce anxiety and improve cooperation during the diagnostic test. Pre-procedure catheterization is not routinely required for IVP and is typically reserved for specific indications. NPO status is generally a pre-procedure requirement (and sometimes briefly afterward per protocol), not maintained until results are available. Promoting contrast elimination is best supported by adequate hydration as ordered rather than hallway ambulation as a primary intervention.

Question 7

The client hospitalized with severe pneumonia asks the nurse, “Why do I need to spit in this sputum specimen container?” Which response is most appropriate?

Accepted Answer

Answer reason: Sputum collection in suspected/confirmed pneumonia is primarily a diagnostic test used for culture and sensitivity to identify the causative organism and guide targeted antimicrobial therapy. This improves effectiveness and supports antibiotic stewardship by avoiding unnecessary broad-spectrum coverage when possible. Simply describing the secretion’s color/amount is observational and does not explain the clinical purpose of a sterile specimen container. Clearing secretions may occur, but it is not the reason the specimen is collected, and it does not address the treatment decision-making need.

Question 8

A client is scheduled to have a chest tube removed. What is the most important intervention for the nurse to perform prior to the removal?

Accepted Answer

Answer reason: Chest tubes are removed only after confirming the underlying problem (e.g., pneumothorax/hemothorax) has resolved and the lung has reexpanded, because premature removal risks recurrent pneumothorax and respiratory compromise. A chest radiograph is the standard diagnostic test used to verify adequate reexpansion and support the provider’s decision to discontinue the tube. Disconnecting the drainage system can allow air to enter the pleural space and is unsafe as a routine pre-removal step. ABGs assess gas exchange but do not confirm pleural resolution, and removing the tube “without warning” is inappropriate because the client must be coached to perform a breath-holding maneuver (e.g., Valsalva/exhalation) to reduce air entry during removal.

Question 9

An echocardiogram has been ordered for a child. What is the most accurate information for the nurse to tell the parents?

Accepted Answer

Answer reason: Echocardiography is an ultrasound-based diagnostic test that visualizes cardiac anatomy and assesses function such as chamber size, wall motion, valve structure, and blood flow patterns. This makes it an accurate, noninvasive way to evaluate suspected congenital or acquired heart problems in children. Sedation is not universally required; many children can complete a transthoracic study with positioning and reassurance, reserving sedation for those who cannot remain still. Transthoracic echocardiography is noninvasive, and while it is very useful, it is not always the single “most definitive” method for every aspect of cardiac evaluation compared with other modalities when indicated.

Question 10

The nurse is preparing a client diagnosed with leukemia for a spinal tap. The nurse determines that the client understands the reason for the procedure when the client states that the procedure is done?

Accepted Answer

Answer reason: A lumbar puncture in leukemia is primarily performed to evaluate whether malignant blasts have spread to the cerebrospinal fluid, which changes staging/risk stratification and drives therapy such as intrathecal chemotherapy. The CSF analysis directly detects CNS involvement and helps guide ongoing monitoring and treatment intensity. While CSF testing can help evaluate infection like meningitis, that is not the routine indication tied specifically to leukemia management. Decreasing ICP is not an indication for spinal tap and can be dangerous if elevated ICP is suspected due to risk of herniation.

Question 11

The nurse reviews the treatment plan for a child recently diagnosed with leukemia who is being evaluated for treatment with chemotherapy. Before the initiation of chemotherapy, the nurse anticipates that which of the following tests will be performed?

Accepted Answer

Answer reason: A lumbar puncture evaluates for leukemic cells in the cerebrospinal fluid and also guides CNS-directed treatment (e.g., intrathecal chemotherapy). This is a key baseline diagnostic test tied directly to treatment planning rather than just general monitoring. Although CBC, peripheral smear, and liver studies are important baseline labs for assessing marrow status and organ function before chemotherapy, they do not specifically assess CNS spread, which changes the regimen and prognosis.

Question 12

A client comes to the emergency department with sudden onset of shortness of breath. The client’s condition deteriorates quickly. The physician suspects a pulmonary embolism. The nurse can expect the physician to order which test?

Accepted Answer

Answer reason: Pulmonary embolism is primarily a problem of perfusion obstruction with relatively preserved ventilation, producing a ventilation–perfusion mismatch that a V/Q study is designed to detect. A V/Q scan can show segmental perfusion defects consistent with embolic occlusion, especially when rapid imaging is needed or when iodinated contrast for CT angiography is undesirable. A chest x-ray is often nonspecific and is mainly used to rule out alternative causes of dyspnea (e.g., pneumonia, pneumothorax), not to confirm PE. Pulmonary function tests are not appropriate in an acutely deteriorating patient and do not diagnose an acute embolic event.

Question 13

The nurse teaches a client how to collect urine for a 24-hour urine collection for protein and creatinine clearance. The nurse knows the client understands how to collect urine when the client states?

Accepted Answer

Answer reason: Accurate 24-hour urine testing requires a precisely timed collection interval so the total analyte excretion over that period can be calculated. Discarding the first morning void establishes the start time with an empty bladder, and then all urine is collected for the next 24 hours including the final void at the end time. Missing any specimen during the interval makes the total volume and measured protein/creatinine excretion falsely low and can invalidate clearance calculations. Midstream technique is used for reducing contamination in urine culture specimens, not for 24-hour quantitative collections.

Question 14

A client presents to the emergency department with abdominal pain, weight loss, steatorrhea, and a random glucose of 417 mg/dl. The nurse should expect which diagnostic test to be ordered?

Accepted Answer

Answer reason: g., pancreatitis or pancreatic malignancy) with exocrine insufficiency and endocrine dysfunction. A noninvasive abdominal ultrasound is a common first-line imaging study to assess the hepatobiliary tree and pancreas and to look for gallstones or biliary obstruction that can precipitate pancreatitis. In contrast, upper/lower GI series and colonoscopy primarily evaluate luminal gastrointestinal conditions and do not directly assess pancreatic or biliary causes of steatorrhea with severe hyperglycemia. Early imaging helps guide urgent management and determine whether more definitive imaging is needed based on initial findings.

Question 15

A client who had a thoracotomy is using oxygen and having an arterial blood gas (ABG) analysis. What is the most appropriate information for the nurse to tell the client?

Accepted Answer

Answer reason: ABGs must reflect the patient’s current oxygenation status under the conditions being delivered at the time of sampling, especially after thoracic surgery where ventilation/perfusion can fluctuate. Keeping supplemental oxygen in place prevents an abrupt change in inspired oxygen that could transiently alter PaO2 and invalidate interpretation of the results. Shaving the puncture site is not a standard preparation for an arterial puncture, and routine NPO status is unnecessary for ABG collection. Suctioning immediately before sampling can acutely change gas exchange and would not be routine unless clinically indicated.

Question 16

The nurse receives orders after notifying an HCP about the client who has tachycardia, diaphoresis, and an elevated temperature after treatments for ALL. Which order should be the nurse’s priority?

Accepted Answer

Answer reason: Obtaining blood cultures (typically from two sites) and a urine culture is time-sensitive and should be done before initiating broad-spectrum antibiotics to avoid sterilizing cultures and losing diagnostic yield. A portable chest x-ray may help identify pneumonia but does not confirm bloodstream infection and is less immediate for directing antimicrobial selection. Filgrastim supports neutrophil recovery but does not address the acute infectious process driving fever and systemic signs.

Question 17

The nurse performs a purified protein derivative (PPD) test on an adult client being screened for TB. The client reports having negative PPD test results in the past. The nurse instructs the client to return and have the results interpreted?

Accepted Answer

Answer reason: PPD (Mantoux) screening is interpreted by assessing induration from a delayed-type (type IV) hypersensitivity response that develops over time. The appropriate reading window is 48–72 hours after placement; reading earlier can miss a developing reaction and yield a false-negative interpretation. Waiting a week is too late because the reaction may diminish and results become unreliable. Past negative results do not change the required timing for accurate interpretation.

Question 18

The nurse is teaching the parents of a child who is scheduled for a cardiac catheterization. Which statement by the nurse is the most accurate regarding cardiac catheterization?

Accepted Answer

Answer reason: Cardiac catheterization is an invasive diagnostic procedure in which a catheter is threaded into the heart and contrast is injected to outline chambers and great vessels under fluoroscopy. This directly supports evaluating structural defects, pressures, oxygen saturations, and blood flow patterns. A common confusion is with echocardiography, which uses high-frequency sound waves and is noninvasive, but that is a different test. General anesthesia is not universally required because sedation/analgesia varies by age, condition, and institutional practice.

Question 19

Which statement made by a parent of a child with short stature would indicate to the nurse the need for further teaching?

Accepted Answer

Answer reason:  Short stature requires evaluation for endocrine, metabolic, and systemic causes, many of which are identified or supported by laboratory testing. Blood studies such as thyroid function tests, IGF-1/IGFBP-3, CBC/chemistry panels, and celiac screening can be essential to distinguish normal variants from treatable pathology. Saying labs are not helpful reflects misunderstanding of the diagnostic workup and indicates a teaching need. By contrast, reviewing growth patterns, obtaining family history, and using imaging (e.g., bone-age radiographs) are all appropriate parts of the assessment.

Question 20

A 17-year-old client who injured his right knee during a basketball game is scheduled for an arthroscopy. The nurse teaches the client about the procedure. Which response by the nurse regarding arthroscopy would be accurate?

Accepted Answer

Answer reason: This description matches the key purpose and method of arthroscopy and is appropriate for client teaching. The contrast X-ray option describes arthrography rather than arthroscopy. The remaining options describe joint or bursal aspiration procedures (arthrocentesis/bursal aspiration), which are different diagnostic/therapeutic interventions.

Question 21

The client calls for the nurse after experiencing sharp chest pains that radiate to the left shoulder. All of the following interventions were prescribed on admission for treating chest pain. Which intervention should the nurse implement first?

Accepted Answer

Answer reason: A STAT 12-lead ECG can identify STEMI or ischemic changes within minutes and triggers urgent reperfusion pathways and medication decisions. Administering nitrates or morphine before confirming rhythm/ischemia can mask symptoms and may be unsafe in certain conditions (e.g., right ventricular infarct or hypotension). Oxygen is not automatically first unless hypoxemia or respiratory distress is present, so immediate ECG best addresses the life-threatening cause while guiding safe subsequent interventions.

Question 22

The client who has pain while walking has an ankle-brachial index (ABI) test. Results show that the client has ratios of 1.4 and 1.3 bilaterally. Based on these results, which should be the nurse’s conclusion?

Accepted Answer

Answer reason: ABI primarily screens for peripheral arterial occlusive disease, where values < 0.90 support PAD and typically correlate with exertional claudication. Ratios of 1.3–1.4 are abnormally high and suggest poorly compressible/calcified arteries (e.g., medial arterial calcification), which can make ABI unreliable for ruling in/out flow-limiting PAD. Therefore the walking pain is not explained by a straightforward low ABI result and needs additional evaluation (e.g., toe-brachial index, Doppler studies, exercise ABI, or other causes of leg pain). Jumping to a specific drug or attributing symptoms to psychological origin is unsafe without clarifying the etiology.

Question 23

The nurse is caring for the client admitted to the antepartum unit at 32 weeks’ gestation with possible preterm labor. The nurse is performing a fetal fibronectin (fFN) test. Which event, if it occurred, would require the nurse to recollect the specimen?

Accepted Answer

Answer reason: fFN is a cervicovaginal diagnostic test whose result can be invalidated by contamination or substances that interfere with the assay. Lubricants can contaminate the sample and cause inaccurate (often false-positive or uninterpretable) results, so a new specimen should be collected if lubricant was used. In contrast, collecting the specimen before a vaginal exam and before other specimens helps avoid disruption/contamination and is recommended. Intercourse within the prior 24 hours can affect testing, but abstaining for 3 days does not create a recollection issue.

Question 24

A nurse is explaining diabetes insipidus to the parents of an infant with the disease. When explaining the diagnostic test that’s used, which comment by a parent would indicate an understanding of the diagnostic test?

Accepted Answer

Answer reason: The key diagnostic study for suspected diabetes insipidus is the water deprivation test, which assesses the kidneys’ ability to concentrate urine when fluids are withheld. Restricting fluids under close monitoring should lead to rising urine specific gravity/osmolality in normal physiology, but urine remains dilute in diabetes insipidus. Because this test can rapidly cause dehydration and hypernatremia—especially in infants—fluid restriction is done in a controlled setting with frequent weights, vital signs, and labs. Offering scheduled fluids or making no intake changes would defeat the purpose of testing renal concentrating ability.

Question 25

A nurse is caring for an infant with suspected developmental dysplasia of the hip (DDH). Which information should the nurse give the parents about diagnostic testing?

Accepted Answer

Answer reason: DDH evaluation uses age-appropriate imaging to confirm suspected instability or dysplasia. After about 4–6 months of age, ossification of the femoral head makes radiography a reliable confirmatory test, whereas earlier assessment is typically by ultrasound. Waiting until walking age delays diagnosis and risks long-term gait and joint complications. Injecting contrast into the subarachnoid space describes myelography and is unrelated to hip dysplasia. Therefore, the statement that radiography confirms the diagnosis best reflects diagnostic testing parents should expect.

Question 26

The nurse cares for a client who is scheduled for an upper GI series. The nurse teaches the client about the test. Which statement by the client indicates an understanding of the nurse’s teaching?

Accepted Answer

Answer reason: An upper GI series is a radiographic study of the esophagus, stomach, and duodenum performed using fluoroscopy/X-rays after the client ingests a contrast agent (typically barium). This statement correctly reflects the essential procedure: drinking contrast while images are obtained. A strong laxative is more characteristic of bowel prep for lower GI/colonoscopy, not an upper GI series. Passing an instrument through the mouth describes endoscopy (EGD), and a CT scan with injected contrast describes CT imaging rather than an upper GI series.

Question 27

The client diagnosed with aortic stenosis scheduled for an echocardiogram tells the nurse, “I am scared. What will they do during the test?” Which statement is the nurse's best response?

Accepted Answer

Answer reason:  Patients expressing fear benefit most from clear, accurate, developmentally appropriate teaching about what to expect from the ordered test. An echocardiogram is a noninvasive ultrasound procedure that uses sound waves to visualize cardiac structures and assess function, which directly addresses the client’s question and can reduce anxiety. The catheter-in-groin description refers to cardiac catheterization, not an echocardiogram, so it provides incorrect information and may increase fear. Responses that only reflect feelings or defer to the provider are less therapeutic here because the nurse can safely explain the basic purpose and method of this diagnostic test.

Question 28

The nurse is providing diabetic education to a group of clients with newly diagnosed diabetes. One of the clients asks why the glycosylated hemoglobin blood test (A1C) is done in addition to the daily capillary blood glucose tests. What is the best response by the nurse?

Accepted Answer

Answer reason: A1C reflects the average proportion of hemoglobin that has been glycated over the lifespan of circulating red blood cells, so it estimates overall glucose control across roughly the prior 2–3 months. Daily capillary glucose checks are point-in-time measurements that vary with meals, activity, illness, and medications, so they cannot summarize long-term trends alone. This makes A1C valuable for evaluating the effectiveness of the overall diabetes management plan and guiding therapy adjustments. Options about hemoglobin level, RBC lifespan as the primary purpose, or serum protein/albumin confuse A1C with other laboratory tests and do not answer why it is done in addition to daily checks.

Question 29

A potential exposure to tuberculosis has occurred at a large, rural high school. The school nurse provides instruction to a group of community nurses who have volunteered to assist in the administration of the Mantoux test for the students. The school nurse determines that further instructions are not required when a volunteer nurse makes which statement?

Accepted Answer

Answer reason: Mantoux (PPD) testing must be interpreted during the defined window because induration peaks at about 48–72 hours and later readings can become less reliable. This statement reflects correct timing for a diagnostic screening test and indicates appropriate understanding of follow-up requirements. By contrast, the test is administered intradermally on the inner forearm (not into the deltoid muscle), and the site should not be rubbed because it can alter the reaction. Results are based on measuring induration, not erythema or a “rash.”.

Question 30

While preparing the client for a computed tomography angiography (CTA), the client asks the nurse what the test Will entail. Which should be the nurse’s correct response?

Accepted Answer

Answer reason:  CTA is a noninvasive CT-based diagnostic test that typically uses IV iodinated contrast to enhance visualization of arterial anatomy. This response accurately prepares the client for what they will experience—an imaging scan plus contrast injection—supporting informed participation and reducing anxiety. The magnetic-fields description refers to MRA/MRI rather than CT, and “small incision into an artery” describes conventional catheter angiography, not CTA. General anesthesia is not routinely required for CTA; at most, clients may receive instructions to hold still or briefly hold their breath, with attention to contrast allergy and renal function screening.

Question 31

The client, who has type I DM, is scheduled for an MRI of the brain after an MVA. Which intervention should the nurse implement to prepare the client for the test?

Accepted Answer

Answer reason: MRI preparation focuses on patient education and safety during a noninvasive diagnostic test, including sensory expectations and comfort measures to support stillness and tolerance. This option directly addresses a common, test-relevant issue (loud acoustic noise) and an appropriate nursing intervention (hearing protection). Routine NPO status and holding insulin is not standard for a non-sedated MRI and creates unnecessary hypoglycemia risk in type 1 diabetes. Post-injection extremity immobilization is relevant to arterial puncture/angiography, not MRI, and renal labs are primarily a concern when IV contrast is planned rather than for a typical MRI.

Question 32

The female client, being treated for stress incontinence with vaginal cone therapy, calls a clinic to report that she is experiencing burning on urination, chills, and fever. Which is the best instruction by the nurse?

Accepted Answer

Answer reason: “Come to the clinic. We need to complete a urine culture and sensitivity.” Dysuria with chills and fever suggests a complicated UTI or possible pyelonephritis, which requires prompt evaluation rather than home measures. Obtaining a urine culture and sensitivity is the key diagnostic step to identify the organism and guide targeted antibiotic therapy. Symptomatic advice alone (antipyretics, fluids, cranberry) may delay definitive treatment and increases risk of ascending infection and sepsis. Stopping vaginal weights does not address the infectious signs and would not be the priority when systemic symptoms are present.

Question 33

In consulting with the HCP, the nurse learns that the client admitted with a possible PE has a ventilation/ perfusion quotient (V/Q) mismatch as shown on a V/Q scan. Which action should be taken by the nurse?

Accepted Answer

Answer reason: A V/Q mismatch indicates an abnormal relationship between ventilation and perfusion and raises suspicion for pulmonary embolism, but it is not definitive in many cases. The nurse should prepare the client for additional confirmatory evaluation (e.g., CT pulmonary angiography, D-dimer, or further imaging) rather than providing premature reassurance. Stating that the scan did not show a PE or that results were normal misinterprets the finding and can delay treatment. Airborne precautions are for transmissible respiratory infections (e.g., TB) and are not indicated for suspected PE.

Question 34

The nurse is preparing the adolescent female client for a renal/bladder ultrasound. Which explanation is most appropriate?

Accepted Answer

Answer reason:  Ultrasound transmission is improved when the bladder is adequately filled, which provides an acoustic window and helps visualize the bladder wall and adjacent pelvic/urinary structures. Holding urine also allows assessment of bladder capacity and, when ordered, comparison of pre- and post-void findings. Emptying the bladder immediately beforehand can reduce visualization and may necessitate delaying the study while the bladder refills. Routine catheterization is not indicated for a standard renal/bladder ultrasound and adds unnecessary risk for discomfort and infection.

Question 35

The nurse is teaching the hospitalized adolescent about collecting a 24-hour urine sample. The adolescent voids, and the nurse discards the void. The adolescent saves all the urine voided in the subsequent 24 hours, and the urine is poured in a collection container that is placed on ice. On the twenty-fourth hour after collection begins, the client voids. What should the nurse do regarding this urine?

Accepted Answer

Answer reason: A 24-hour urine collection must include all urine produced during the exact timed interval to ensure accurate total analyte excretion. After the initial “start” void is discarded, every subsequent void is saved, including the final void at the 24-hour endpoint. Omitting the last specimen would produce a falsely low result and invalidate the collection. Keeping the container chilled preserves specimen integrity by limiting bacterial growth and chemical degradation.

Question 36

A chest X-ray shows a client’s lungs to be clear; however, the Mantoux test is positive with 10 mm of induration, and the previous test was negative. The nurse explains to the client that these test results are possible because?

Accepted Answer

Answer reason: A newly positive Mantoux after a prior negative indicates new TB infection (tuberculin conversion), even when a chest X-ray is clear. A clear X-ray helps rule out active pulmonary disease but does not exclude latent TB infection, which can still yield a positive skin test. The 10 mm induration meets positivity criteria for several at-risk groups and supports recent infection in the context of a documented change from negative to positive. Prior treated TB can leave tests positive, but that would not explain a previously negative baseline test with subsequent conversion. “Seroconversion” is not the correct concept for TB skin testing and does not imply bloodstream spread.

Question 37

A client tells the nurse that he has not been following his prescribed diabetes management program and is concerned because he is visiting his doctor for his routine 3-month assessment. He asks if the doctor will be able to determine his lack of compliance from the blood work. The nurse is aware that the best indicator of a client’s diabetic control over the past 2 or 3 months is which measure?

Accepted Answer

Answer reason: Because it integrates many daily highs and lows, it is less affected by short-term factors like recent meals, stress, or a single missed dose. In contrast, a fasting glucose is only a point-in-time value and can look “normal” despite frequent hyperglycemia at other times. Oral glucose tolerance testing is mainly used for diagnosing impaired glucose tolerance/diabetes rather than monitoring long-term control. Self-monitoring records can be incomplete or inaccurate and do not provide an objective lab-based summary of control.

Question 38

A 50-year-old client is admitted to the emergency department with severe lower back pain, weakness, and atrophy of the leg muscles. Based on the clinical manifestations, which diagnostic tests would the nurse expect the physician to order?

Accepted Answer

Answer reason: g., herniated disc, spinal stenosis, or tumor), where the key need is to visualize vertebrae, discs, and neural structures. MRI is the preferred study for soft-tissue detail and identifying nerve root or spinal cord impingement, while CT adds excellent bony detail and can further define structural causes. Myelography (often CT myelography) helps delineate the spinal canal and nerve root compression when MRI is inconclusive or contraindicated. Chest X-ray and lumbar puncture do not directly evaluate suspected lumbosacral compressive pathology and are not first-line for this presentation.

Question 39

The client has undergone a lymph node biopsy to differentiate between Hodgkin’s and non-Hodgkin’s lymphoma. After reviewing the client’s lymph node biopsy results, which revealed that the client has Hodgkin’s lymphoma, the nurse should obtain which educational brochure?

Accepted Answer

Answer reason: Teaching that focuses on these hallmark cells directly explains how the diagnosis was confirmed and distinguishes it from non-Hodgkin’s lymphoma. Reticulocyte count relates more to bone marrow response to anemia/hemolysis rather than lymphoma identification. CA-125 is primarily associated with ovarian and some other epithelial cancers, not Hodgkin’s lymphoma, and an elevated WBC count is nonspecific and not diagnostic.

Question 40

The child is to have a breath hydrogen test to evaluate for malabsorption syndrome. Which instruction is most important for the nurse to include when teaching the parents about the preparation needed for the test?

Accepted Answer

Answer reason: Breath hydrogen testing relies on intestinal bacterial fermentation of unabsorbed carbohydrates, so pretest diet must minimize fermentable carbs to avoid falsely elevated baseline hydrogen. A simple, low-residue meal (meat, rice, water) the evening before reduces colonic substrate and improves test accuracy. Antibiotics close to the test can suppress gut flora and distort results rather than improve them. Enemas and extra fluids immediately before testing are not standard preparation steps and can interfere with fasting/pretest conditions needed for reliable measurements.

Question 41

A client arrives at the emergency department complaining of chest and stomach pain and a report of black, tarry stools for the past 2 months. Which orders should the nurse anticipate?

Accepted Answer

Answer reason: An ECG is needed immediately to evaluate cardiac ischemia, while a CBC assesses hemoglobin/hematocrit for the severity of bleeding. Testing for occult blood supports GI bleeding evaluation when stool appearance/history is concerning, and a comprehensive metabolic panel helps assess renal function and electrolytes relevant to perfusion, volume status, and safe treatment planning. Coagulation/DIC studies or neurologic/hepatic enzyme-focused testing are not the most targeted initial orders for this presentation.

Question 42

An elderly client complains of difficulty beginning a urine stream and sensing a full bladder even after urination. The physician performs a digital rectal exam and has the nurse draw blood for prostate specific antigen (PSA). The nurse knows the physician ordered a PSA because?

Accepted Answer

Answer reason: PSA is primarily used as a screening/adjunct diagnostic blood test to help assess risk of prostate cancer in men with prostate-related urinary symptoms. Lower urinary tract symptoms can be caused by BPH, but cancer must be considered because symptoms overlap and DRE alone cannot reliably exclude malignancy. PSA does not confirm BPH and prostate size/enlargement is better assessed by DRE and imaging/uroflow studies rather than PSA. It also does not diagnose a UTI, which is evaluated with urinalysis and urine culture.

Question 43

The nurse assists a client diagnosed with a renal disorder in collecting a 24-hour urine specimen. Which intervention does the nurse implement to ensure proper collection of the 24-hour urine specimen?

Accepted Answer

Answer reason: A 24-hour urine collection must represent exactly the urine produced after the official start time through the end of the 24-hour period. Discarding the first void establishes an empty bladder at time zero so that all subsequently produced urine is captured within the timed window. Including the start-time void would add urine formed before the collection period and can falsely elevate measured excretion values. Proper handling also typically includes keeping the specimen chilled during collection, but the key step that ensures timing accuracy is discarding the initial void.

Question 44

You have an order to place a nasogastric tube on a patient with a small bowel obstruction. What is the best way to confirm placement after insertion?

Accepted Answer

Answer reason: Radiographic confirmation is the gold standard and most definitive method after insertion, especially before using the tube for suction or instillation. Bedside clinical checks (e.g., breath sounds/dyspnea) are not sensitive enough to exclude airway placement. Assessing aspirate appearance alone can be misleading and should not replace imaging confirmation. Patient comfort or bowel sounds do not confirm tube location.

Question 45

The nurse is caring for a neonate who the nurse suspects has neonatal sepsis from group beta streptococcus (GBS). Which of the following actions should the nurse take?

Accepted Answer

Answer reason: Suspected neonatal sepsis requires rapid diagnostic evaluation and prompt empiric IV antibiotics, and cultures should be obtained first when possible to identify the pathogen and guide targeted therapy. Drawing blood cultures before antibiotics increases diagnostic yield and helps confirm GBS or other organisms. Oral antibiotics are not appropriate for neonatal sepsis because reliable therapeutic serum levels and broad empiric coverage are needed via IV route. Contact precautions are not routinely required for GBS sepsis (standard precautions are used), and breastfeeding is not a transmission risk for GBS in this context, so switching to formula is unnecessary.

Question 46

A patient is admitted to the hospital with complaints of nausea, vomiting, diarrhea, and severe abdominal pain. Which of the following would immediately alert the nurse that the patient has bleeding from the GI tract?

Accepted Answer

Answer reason: This bedside screening can detect blood even when it is not grossly visible, making it an immediate indicator that bleeding is occurring in the GI tract. A complete blood count may show anemia, but hemoglobin/hematocrit can remain normal early in acute bleeding due to delayed hemodilution. Vital signs reflect physiologic response (e.g., tachycardia, hypotension) but are nonspecific and can be abnormal from dehydration due to vomiting/diarrhea. Abdominal girth may suggest distention/ascites rather than GI bleeding.

Question 47

What is the most important initial assessment for a nurse to perform when a patient is admitted with acute chest pain?

Accepted Answer

Answer reason: A 12-lead ECG is the key initial diagnostic test for acute chest pain because it can detect STEMI/NSTEMI patterns and high-risk dysrhythmias within minutes. Vital signs like blood pressure and respiratory rate are important, but they do not rule in or rule out myocardial infarction and should not delay early ECG acquisition. Early ECG results directly determine urgency of escalation (e.g., cath lab activation) and targeted therapies. Temperature is least critical initially because fever evaluation is not the priority in potentially life-threatening cardiac ischemia.

Question 48

A nurse is caring for a client with rheumatoid arthritis. Based on the client's diagnosis, the nurse should review the result of which laboratory test?

Accepted Answer

Answer reason: ANA is a nonspecific autoimmune marker that may be positive in rheumatoid arthritis and helps screen for overlapping connective-tissue diseases that can alter monitoring and management. Pancreatic lipase is used for pancreatitis, not inflammatory arthritis. Bence Jones protein is associated with multiple myeloma, and alkaline phosphatase is more aligned with hepatobiliary or bone turnover evaluation rather than primary RA immunologic workup.

Question 49

A clinic nurse is assessing a homeless patient who is complaining of night sweats and a cough. The provider orders a Mantoux test. Which of the following is accurate regarding a Mantoux test?

Accepted Answer

Answer reason: The correct reading window is 48 to 72 hours; readings outside this timeframe can miss peak induration or become unreliable. It is not given subcutaneously or intramuscularly, and patients should not be taught to self-interpret because accurate measurement requires trained assessment of induration (not erythema). A 15-minute observation period applies to immediate hypersensitivity reactions to some injections, but Mantoux results are not immediate.

Question 50

Which of the following is not required prior to an EEG?

Accepted Answer

Answer reason: Pre-test instructions typically focus on optimizing signal quality and provoking abnormalities, which is why clean, dry hair (no oils/products), avoidance of stimulants like caffeine, and sometimes sleep deprivation may be requested. Fasting is generally unnecessary because the test does not involve contrast, anesthesia, or procedures that increase aspiration risk. NPO would only be considered in special circumstances (e.g., planned sedation), not as a standard requirement.

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