Question 1

Which electrode would be placed at the fourth intercostal space, right sternal border for a 12 lead EKG?

Accepted Answer

Answer reason: The right sternal border at the 4th intercostal space is the standard landmark for the first precordial lead. V2 is placed at the 4th intercostal space at the left sternal border, and V3 sits midway between V2 and V4. V5 is placed at the left anterior axillary line at the same horizontal level as V4, making it incorrect for this location.

Question 2

Prior to receiving a hysterosalpingogram, the nurse should assess a patient for allergies to which substances?

Accepted Answer

Answer reason: The key pre-procedure safety step is to screen for prior reactions to iodinated contrast because hypersensitivity can range from urticaria to anaphylaxis. Identifying this risk allows planning for alternative contrast, premedication protocols, and emergency preparedness. Adhesive and penicillin allergies are not specifically tied to the contrast agent used for this diagnostic test.

Question 3

The normally healthy adolescent client has a 5-mm skin induration 72 hours after receiving a tuberculin skin test. Which conclusions should the nurse make regarding the test results?

Accepted Answer

Answer reason: For individuals with no risk factors, an induration of ≥15 mm is considered positive. An induration of 5 mm is only considered positive in high-risk groups (e.g., immunocompromised clients). Therefore, this result is negative in a normally healthy adolescent. Option B is incorrect because a skin test does not diagnose active TB. Option C is unnecessary for a negative result. Option D is incorrect because the test is appropriately read at 48–72 hours.

Question 4

A client presents to the emergency unit with retrosternal chest pain on exertion, which is relieved by rest. Which of the following tests should the nurse anticipate to be ordered?

Accepted Answer

Answer reason: Troponin is the most specific and clinically preferred marker of myocardial injury and guides urgent management decisions alongside ECG findings. BNP/ANP are markers of volume overload and heart failure rather than ischemic chest pain evaluation. Myoglobin can rise early but lacks cardiac specificity, so it is not the best single test among the options.

Question 5

The nurse is educating a female patient on how to collect a midstream clean catch urine sample. Which of the following instructions should be included?

Accepted Answer

Answer reason: Separating the labia during voiding reduces contact of urine with skin and vaginal secretions, improving specimen integrity. The container should be introduced after the initial urine stream begins to obtain the midstream portion rather than the first flow, which is more contaminated. The specimen must be collected in a sterile container and only a sufficient amount is needed, so filling the container or using an arbitrary container increases contamination risk.

Question 6

A 55-year-old female client presents to the emergency department reporting bright red blood per rectum. Oriented to person, place, and time. Appears jaundiced. Denies cough, shortness of breath. Reports dull lower abdominal pain. Experiencing constipation over the last two months. Takes no medications. Reports that she has not been to a healthcare provider since she was a child when her mother died in this hospital. The nurse reviews the client’s History and Physical. Which diagnostic study is the priority for the nurse to facilitate at this time?

Accepted Answer

Answer reason: g., hemorrhoids, fissure, rectal mass) and help guide immediate next diagnostic steps. This exam is fast, low risk, and can be performed promptly in the ED without bowel prep or sedation, making it the most immediately actionable study to facilitate. Colonoscopy is important for ongoing evaluation of possible colorectal cancer given constipation and abdominal pain, but it is not the first study to facilitate because it requires preparation and coordination. FOBT is inappropriate when overt bleeding is already present, and LFTs address jaundice but do not take priority over initial localization/assessment of the active lower GI bleeding source.

Question 7

A patient presents to the emergency room with complaints of left sided calf pain and swelling. Which laboratory test should the nurse anticipate to test for the presence of blood clots?

Accepted Answer

Answer reason:  D-dimer is a fibrin degradation product that rises when clot formation and breakdown have occurred, making it a key screening lab when DVT/PE is suspected. Calf pain and unilateral swelling are classic for possible deep vein thrombosis, where an elevated result supports the presence of recent thrombosis and prompts confirmatory imaging (e.g., venous duplex ultrasound). In contrast, PT/INR and aPTT assess coagulation pathways and are primarily used to monitor anticoagulant therapy (warfarin for PT/INR; heparin for aPTT) rather than detect an existing clot. A normal result is most helpful to help rule out thrombosis in low-risk patients, while an elevated result is nonspecific and must be interpreted in clinical context.

Question 8

Which of the following tests should be administered to a client suspected of having diverticulosis?

Accepted Answer

Answer reason: A contrast enema outlines the colonic lumen and can reveal multiple diverticula as filling defects and contour changes. The swallow study targets the esophagus/stomach and does not assess colonic disease, and gastroscopy evaluates the upper GI tract rather than the colon. Abdominal ultrasound may assess other abdominal pathology but is not the standard test to visualize colonic diverticula.

Question 9

Which test is considered the gold standard for diagnosing cystic fibrosis?

Accepted Answer

Answer reason: The sweat chloride test is the gold standard for diagnosing cystic fibrosis. It measures elevated chloride levels in sweat due to defective CFTR channels. Genetic testing supports diagnosis but is not the primary diagnostic standard.

Question 10

A patient arrives at the emergency department with chest pain, diaphoresis, and shortness of breath. The nurse suspects a myocardial infarction (MI). Which intervention should be performed first?

Accepted Answer

Answer reason: A 12-lead ECG should be obtained immediately in suspected myocardial infarction to confirm diagnosis and guide urgent reperfusion therapy. Early identification is critical for reducing myocardial damage. Other interventions follow once diagnosis is established.

Question 11

Which of the following statements should the nurse use when educating a patient on completing a fecal occult blood test?

Accepted Answer

Answer reason: FOBT/FIT screening aims to detect intermittent, microscopic GI bleeding, so collecting specimens from more than one bowel movement increases sensitivity and reduces false-negative results. This instruction aligns with typical kit directions to sample different stools (often on different days) rather than relying on a single specimen. Taking stool from the toilet risks dilution/contamination with water or cleaning agents, which can compromise test accuracy. Testing visibly bloody stool is inappropriate for occult testing and instead warrants clinical evaluation for overt GI bleeding.

Question 12

A male client with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse position the client for this test initially?

Accepted Answer

Answer reason: Flexing the hips and knees reduces abdominal wall tension and improves patient comfort while allowing optimal scope manipulation. Right lateral positioning is commonly used after the procedure during recovery, not as the initial position for insertion. Prone or standing/bent-over positions are not standard for colonoscopy and can increase discomfort and compromise safety with sedation and monitoring.

Question 13

The right forearm of a client who had a purified protein derivative (PPD) test for tuberculosis is reddened and raised about 3mm where the test was given. This PPD would be read as having which of the following results?

Accepted Answer

Answer reason: A 3 mm induration is below all standard positive thresholds (e.g., ≥5 mm for highest-risk groups, ≥10 mm for moderate risk, ≥15 mm for no risk factors). Therefore the finding is read as a negative test result. A common error is calling any redness “positive,” but erythema alone does not determine reactivity.

Question 14

A client with sarcoma is receiving Bleomycin (Blenoxane). The nurse in charge of the client expects the physician to order which diagnostic procedure?

Accepted Answer

Answer reason: Baseline and serial assessment of lung function (often including DLCO) helps detect early impairment so therapy can be adjusted before irreversible damage occurs. The other listed tests primarily evaluate cardiac ischemia/rhythm or intracranial pathology and do not target the key organ-specific risk of this medication. Monitoring respiratory status with objective pulmonary testing is therefore the most relevant diagnostic procedure to expect.

Question 15

A 32-year-old with persistent tachycardia presents to the clinic. An electrocardiogram shows sinus tachycardia. Basic metabolic panel, troponin level, hydration status, CT scan of the chest, chest x-ray, and other vitals are all within normal limits. What should the nurse ask the provider for next?

Accepted Answer

Answer reason: Thyroid hormone excess increases beta-adrenergic activity and resting heart rate, making thyroid testing an appropriate next diagnostic step when cardiac ischemia, dehydration, and pulmonary causes have been reasonably excluded. Atropine is used for symptomatic bradycardia and would worsen tachycardia. Synchronized cardioversion is reserved for unstable tachyarrhythmias or certain non-sinus rhythms, not stable sinus tachycardia.

Question 16

A client is scheduled for a fecal fat exam. In planning client education, the nurse includes that which dietary modification is necessary before the test?

Accepted Answer

Answer reason: Fecal fat testing evaluates fat malabsorption, so the patient must consume a standardized high-fat diet beforehand to ensure the test can detect steatorrhea if present. Adequate fat intake over several days helps avoid a falsely low fecal fat result from insufficient dietary fat rather than normal absorption. A single high-fat meal immediately before testing is not sufficient to standardize multi-day stool fat excretion. A fat-free diet would directly undermine the purpose of the test and can yield misleading results.

Question 17

A client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed?

Accepted Answer

Answer reason: Monitoring for early changes in lung diffusion/capacity helps detect toxicity before severe, irreversible impairment occurs. Pulmonary function testing (often including DLCO) is therefore a high-yield diagnostic follow-up when this medication is administered. Cardiac studies (ECG/echo) are more characteristic monitoring for cardiotoxic agents like anthracyclines rather than bleomycin.

Question 18

The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions?

Accepted Answer

Answer reason: An EEG records electrical activity generated by cerebral cortex neurons and is used to assess brain function (e.g., seizure activity, encephalopathy, and supportive evidence of brain death when appropriate). In a client who is unconscious after a massive hemorrhage, this test helps determine whether organized cortical electrical activity is present or absent. The extent of bleeding and anatomic injury localization are better evaluated with neuroimaging such as CT or MRI rather than EEG. EEG also cannot quantify the percent of functional brain tissue; it reflects electrical patterns, not tissue viability measurements.

Question 19

A client with a positive Mantoux test result will be sent for a chest x-ray. For which of the following reasons is this done?

Accepted Answer

Answer reason: A positive Mantoux (PPD) indicates prior sensitization to TB antigens but does not distinguish latent infection from active pulmonary disease. A chest x-ray is obtained to evaluate for radiographic evidence consistent with active tuberculosis and to guide next diagnostic steps and infection-control decisions. This makes it the appropriate follow-up test to help confirm whether there is active disease rather than just a positive immune response. Repeating the skin test is not the purpose once a result is already positive, and classifying primary vs secondary TB is not the key clinical goal of the initial x-ray.

Question 20

The client being seen in a physician’s office has just been scheduled for a barium swallow the next day. The nurse writes down which of the following instructions for the client to follow before the test?

Accepted Answer

Answer reason: Upper GI contrast studies require an empty stomach to optimize visualization and reduce the risk of aspiration during swallowing of contrast. Being NPO for about 8 hours is standard pre-procedure preparation to prevent residual food/fluid from obscuring the esophagus and stomach. Eating a regular breakfast would directly interfere with test accuracy and safety. Constipation monitoring is a key post-procedure instruction because barium can harden and cause impaction, but it is not the primary instruction to follow before the test.

Question 21

SITUATION: The client claims to have had a diagnostic workup at the outpatient unit before admission but cannot show the results of the tests. The admitting nurse prepares the client for which of the following procedure Which is most likely to confirm the presence of a brain tumor?

Accepted Answer

Answer reason: Neuroimaging is the key confirmatory approach for an intracranial mass because it can directly visualize a space-occupying lesion, associated edema, and mass effect. CT is widely available, rapid, and can identify many tumors and complications such as hemorrhage or hydrocephalus, making it a practical confirming study on admission. Lumbar puncture is not used to confirm a brain tumor and can be dangerous if increased intracranial pressure is present due to risk of herniation. Skull x-ray is insensitive for intracranial tumors, and a myelogram evaluates spinal canal pathology rather than brain lesions.

Question 22

The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client’s chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?

Accepted Answer

Answer reason: Herpes zoster is caused by reactivation of varicella-zoster virus, so a definitive test targets identification of the causative organism from lesion material. Viral testing/culture (or other direct viral detection methods) supports a specific infectious etiology rather than a nonspecific inflammatory pattern. Patch testing evaluates allergic contact dermatitis and does not diagnose a viral neuropathic eruption. Wood’s lamp findings apply to certain fungal/bacterial skin infections and are not used to confirm this condition.

Question 23

A male client with acute pyelonephritis receives a prescription for co-trimoxazole (Septra) P.O. twice daily for 10 days. Which finding best demonstrates that the client has followed the prescribed regimen?

Accepted Answer

Answer reason: The core principle is that the most objective indicator of effective antibiotic adherence in a bacterial kidney infection is microbiologic eradication. A negative follow-up urine culture demonstrates that the causative organism has been cleared, which directly reflects adequate dosing and duration. Symptom improvement (e.g., less flank pain) can occur even with incomplete treatment and does not confirm cure. Urine output and a normal peripheral RBC count are nonspecific and do not measure resolution of urinary tract infection.

Question 24

A patient arrives at the emergency department with severe lower leg pain after a fall in a touch football game. Following routine triage, which of the following is the appropriate next step in assessment and treatment?

Accepted Answer

Answer reason: After an acute fall with severe focal lower-leg pain, the priority is to evaluate for fracture or significant bony injury before initiating interventions that could worsen displacement or compromise neurovascular status. Plain radiography is the standard initial diagnostic test to confirm or rule out fracture and guide immobilization and further management. Compression with an elastic bandage can be inappropriate if there is an undiagnosed fracture or evolving compartment syndrome. Analgesia is important but does not replace immediate diagnostic evaluation when a serious injury is suspected, and heat is not indicated in the acute post-injury period due to increased bleeding/inflammation.

Question 25

A fragile 87-year-old female has recently been admitted to the hospital with increased confusion and falls over the last two (2) weeks. She is also noted to have a mild left hemiparesis. Which of the following tests is most likely to be performed?

Accepted Answer

Answer reason: Non-contrast head CT is the rapid, first-line test to identify acute hemorrhage, mass effect, and many structural causes needing urgent management. While CBC, ECG, and thyroid studies can contribute to a delirium workup, they do not directly evaluate the most dangerous, time-sensitive cause implied by focal findings. The presence of lateralizing weakness makes neuroimaging the highest-yield and safest immediate diagnostic step.

Question 26

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority?

Accepted Answer

Answer reason: Acute unilateral weakness and slurred speech suggest stroke, and immediate differentiation between ischemic and hemorrhagic causes guides all subsequent treatment. A non-contrast head CT is the urgent diagnostic test needed to rule out intracranial hemorrhage before any thrombolytic therapy can be considered. Administering r-tPA without first excluding hemorrhage can cause catastrophic bleeding, so it cannot be the first action. History-taking and speech pathology consultation are important but do not address the time-critical need to confirm stroke type and eligibility for emergent therapy.

Question 27

A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test?

Accepted Answer

Answer reason: CT imaging for a suspected brain tumor commonly uses iodinated IV contrast, which can trigger hypersensitivity reactions ranging from urticaria to anaphylaxis. Pre-procedure nursing preparation prioritizes screening for prior reactions to iodinated contrast (and documenting related allergy history) so appropriate precautions (e.g., premedication, alternative imaging, or close monitoring) can be arranged. This action directly reduces the risk of an acute life-threatening complication during the diagnostic test. The other options are not routine CT-prep safety steps for contrast exposure; sedation is only indicated for severe anxiety/claustrophobia or inability to remain still, not universally required.

Question 28

The nurse is admitting a patient diagnosed with pneumonia. Which healthcare provider’s order should be implemented first?

Accepted Answer

Answer reason: Diagnostic specimens should be collected before starting antibiotics to avoid suppressing bacterial growth and producing a false-negative culture. This action directly supports identifying the causative organism and guiding targeted antimicrobial therapy, improving outcomes and antimicrobial stewardship. Initiating ceftriaxone first can reduce culture yield and limit the ability to tailor therapy if the patient does not respond as expected. IV fluids and nebulization may be helpful supportive measures, but they do not have the same time-sensitive impact on diagnostic accuracy for selecting definitive treatment.

Question 29

A patient with a pulmonary embolus and a nursing diagnosis of impaired gas exchange has an order to obtain arterial blood gases. The FIRST intervention by the nurse is to?

Accepted Answer

Answer reason: Arterial blood gas collection requires specific items (heparinized syringe, antiseptic, labels, ice, bandage), and delays while searching for supplies can worsen hypoxemia risk in a patient with pulmonary embolus. After equipment is ready, the nurse should provide focused teaching/verification of understanding and then assess collateral circulation (Allen test) before radial puncture. Documentation occurs after the procedure is completed and results/response are addressed.

Question 30

The nurse provides care for a client who is confused and reports a headache. The client's vital signs are as follow: temperature 101.0°F (38.3°C), BP 150/64 mm Hg, pulse 58 beats/min, and irregular respirations of 12 breaths/min. Which action does the nurse take next?

Accepted Answer

Answer reason: The combination of headache, confusion, hypertension with widened pulse pressure, bradycardia, and irregular respirations is concerning for increased intracranial pressure (Cushing response) and possible intracranial pathology. The safest next step is urgent neuroimaging to identify mass effect or hemorrhage before any procedure that could precipitate herniation. An LP is contraindicated until a space-occupying lesion is ruled out because it can rapidly worsen brain shift. Lowering the head of the bed can increase intracranial pressure, and giving IV opioids can depress respirations and obscure neurologic assessment when intracranial pathology is suspected.

Question 31

The nurse is caring for a client who is scheduled to undergo a pharmacological nuclear stress test later in the morning. Which action is most important for the nurse to take?

Accepted Answer

Answer reason: g., hypotension, bronchospasm, dysrhythmias). Establishing a reliable IV before transport prevents delays that could invalidate timing-sensitive imaging and improves safety if emergency medications are required. Holding “morning medications” is not universally indicated because only specific agents (e.g., caffeine, certain antianginals or beta-blockers depending on protocol) are withheld per provider/test protocol rather than as a blanket nursing action. Fluids and pedal-pulse marking are not core preparation steps for this diagnostic procedure and do not address the highest pretest safety need.

Question 32

The nurse is caring for a patient with a spinal cord injury. Which diagnostic test would be most precise for determining the degree of damage/spinal compromise?

Accepted Answer

Answer reason: This makes it the best test to determine the degree of neurologic tissue damage and the extent of spinal canal compromise. CT and plain cervical x-rays are superior for bony detail and fracture alignment but are less precise for cord/ligament injury severity. Vertebral angiography evaluates vascular injury (e.g., vertebral artery dissection) and does not quantify cord damage or compression as the primary goal.

Question 33

How should a nurse interpret a negative 12-panel urine toxicology screen for a client that is prescribed amphetamine salts? The client has?

Accepted Answer

Answer reason: Urine drug screens reflect recent exposure and are limited by each drug’s detection window rather than whether a medication was ever prescribed. Amphetamines are typically detectable in urine for only a few days after the last dose in most patients, so a negative result is most consistent with no recent ingestion. A 30-day nonuse is far beyond usual urine detection for amphetamines and is therefore unnecessarily long. Overuse would be expected to increase the likelihood of a positive screen rather than a negative one, assuming adequate test sensitivity and proper specimen handling.

Question 34

A client relieves severe abdominal pain that radiates to the back by sitting forward with the knees bent. Which laboratory test will the nurse expect to be prescribed for this client?

Accepted Answer

Answer reason: The classic presentation of acute pancreatitis includes severe epigastric pain radiating to the back that is relieved by leaning forward with knees flexed, due to reduced tension on inflamed pancreatic/peritoneal tissues. In suspected pancreatitis, pancreatic enzymes rise in the blood, so ordering a pancreatic enzyme assay is an expected diagnostic lab. This option directly assesses pancreatic inflammation/injury, helping confirm the suspected condition and guide further management. In contrast, creatinine and blood urea nitrogen primarily evaluate renal function/volume status, and creatinine kinase reflects muscle injury rather than pancreatic pathology.

Question 35

The nurse is reading the results of the client’s tuberculin skin test and palpates a 4-mm area of induration at the test site. The nurse should document which result?

Accepted Answer

Answer reason: An induration of 4 mm is below the lowest commonly used positive cutoff (5 mm) and is therefore documented as a negative result in the absence of special circumstances. Nursing documentation should record the induration size and the interpretation, but the test does not diagnose active disease. A common error is charting that it confirms or conclusively determines tuberculosis, which is incorrect because it only indicates immune sensitization when positive.

Question 36

The nurse is preparing to perform an electrocardiogram (ECG) for an assigned client. Which of the following actions should the nurse take?

Accepted Answer

Answer reason: A standard 12-lead ECG requires correct lead placement to capture electrical activity from multiple vectors and produce an interpretable tracing. Limb electrodes are placed on the four extremities (or their proximal substitutes) and precordial electrodes are placed across the chest to obtain the chest leads. Gel and a transducer are used for ultrasound-type studies, not routine ECG acquisition. Semi-Fowler’s positioning can be helpful for comfort but is not the essential, test-defining preparation step, and IV access is not required to perform an ECG.

Question 37

A patient recovering from tuberculosis is wondering when they will no longer be contagious. Which of the following diagnostic tests will confirm with the most certainty that this patient is no longer infectious?

Accepted Answer

Answer reason: Infectiousness in tuberculosis is determined by evidence of active disease and ongoing bacillary burden rather than by immune sensitization alone. A Mantoux test can remain positive long after infection is controlled and therefore cannot indicate non-contagious status. Blood cultures are not the standard method for assessing pulmonary TB contagiousness, and a single negative sputum culture may be insufficient due to intermittent shedding and sampling variability. Combining testing that supports microbiologic clearance with imaging showing no active pulmonary disease provides the greatest certainty among the listed choices that the patient is no longer infectious.

Question 38

The nurse is caring for a patient with urolithiasis. The patient needs to be evaluated to determine the type of stone before treatment can begin. The nurse would use which of the following to assist this process?

Accepted Answer

Answer reason: g., calcium oxalate, uric acid, struvite, cystine) guides targeted prevention and treatment. Straining all urine allows the nurse to catch even small stones or fragments and send them for analysis promptly. A 24-hour collection evaluates urine chemistries (risk factors) but does not reliably provide the stone itself for composition testing. A sterile urinal and an intake/output sheet help with collection convenience and monitoring volume, but they do not directly capture the stone for identification.

Question 39

The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis?

Accepted Answer

Answer reason: An elevated ASO titer indicates a recent Streptococcus pyogenes exposure and supports meeting the Jones criteria when combined with clinical findings. In contrast, WBC count is a nonspecific marker of inflammation/infection and does not link symptoms to prior streptococcal disease. RBC count and nonspecific immunoglobulin levels do not provide targeted confirmation of antecedent streptococcal infection.

Question 40

A nurse cares for a client with suspected tuberculosis. Which test confirms this diagnosis?

Accepted Answer

Answer reason: Culture of sputum provides confirmatory evidence by growing the organism (and allows drug-susceptibility testing), making it the gold standard. The Mantoux skin test indicates exposure/latent infection and can be false-positive with BCG vaccination or non-tuberculous mycobacteria, so it does not confirm active disease. A chest x-ray can show suggestive findings but is not specific and cannot establish the diagnosis without microbiologic confirmation.

Question 41

A patient is seen at the clinic for a routine physical examination. After the patient is assessed for evidence of peripheral vascular disease (PVD), which of the following tests does the nurse explain is typically used to assist in the diagnosis?

Accepted Answer

Answer reason: A reduced ratio indicates impaired arterial blood flow to the legs and supports the diagnosis of PVD/PAD, often before advanced imaging is needed. Allen's test evaluates collateral circulation in the hand (radial/ulnar patency) and is not used to diagnose lower-extremity PVD. Cardiac stress testing and echocardiography evaluate coronary ischemia and cardiac structure/function rather than peripheral arterial perfusion.

Question 42

A client in the postpartum unit has a temperature of 100.9 F (38.3 C) and tachycardia on the second day following a cesarean delivery. The nurse assessment shows uterine tenderness, fundus +2 above the umbilicus, moderate lochia rubra with a foul smell, and chills. Which prescription should the nurse implement first?

Accepted Answer

Answer reason: Foul-smelling lochia, uterine tenderness, fever, chills, and tachycardia after cesarean strongly suggest a uterine infection with potential progression to sepsis. Drawing blood cultures first avoids falsely negative results that can occur if broad-spectrum antibiotics are given immediately. After cultures are obtained, establishing IV access and initiating ordered broad-spectrum antibiotics are the next critical steps, while antipyretics address comfort but do not treat the underlying infection.

Question 43

A health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV). The nurse anticipates that which laboratory study will be prescribed for the infant?

Accepted Answer

Answer reason: A virologic test that detects viral components is therefore needed to identify true infection early in life. The p24 antigen assay detects HIV antigen (a viral protein), supporting early diagnosis when antibody tests like Western blot may be falsely positive from maternal antibodies. CD4+ cell count helps stage immune suppression after infection is confirmed, and chest x-ray is not a primary diagnostic test for establishing HIV infection.

Question 44

In order to rule out laryngeal cancer, the physician performed direct visualization of the patient's larynx. Which of the following should the nurse tell the patient to do so that there will be a reduced sensation of gagging during the procedure?

Accepted Answer

Answer reason: " Controlled nasal breathing helps suppress the gag reflex by promoting relaxation and minimizing oropharyngeal stimulation during laryngeal visualization. Deep, steady breaths also help the patient remain still and reduce anxiety, which can otherwise heighten gagging. Swallowing increases pharyngeal movement and can worsen the sensation and interfere with the examiner’s view. Holding the breath can increase discomfort and tension and does not physiologically reduce the gag reflex.

Question 45

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 test detects hidden blood even when stool appearance is not clearly melena or hematochezia, making it an immediate alert for GI tract bleeding in a symptomatic patient. Vital signs can suggest volume loss but are nonspecific and may remain normal early due to compensation. A complete blood count helps quantify anemia but often lags behind acute blood loss, and abdominal girth is more relevant to ascites/obstruction than bleeding.

Question 46

While providing education to the client diagnosed with cancer, what statement best explains the purpose of testing tumor markers?

Accepted Answer

Answer reason: " Tumor markers are measurable substances associated with certain cancers and are most useful for monitoring response to therapy, detecting recurrence, and sometimes helping with prognosis in combination with other findings. They do not determine tumor size, nodal status, or distant spread; those are established with staging workups such as imaging and tissue biopsy. Client teaching should clarify that tumor marker levels can rise for reasons other than cancer and are interpreted as trends rather than a stand-alone diagnostic or staging tool. Options describing benign look-alike tumors, life expectancy determination, or future cancer risk factors do not reflect the clinical purpose of tumor marker testing.

Question 47

Which of the following can cause hemolysis in a blood sample?

Accepted Answer

Answer reason: Drawing blood through a small-gauge needle increases shear stress and turbulence, which can rupture RBC membranes and release intracellular contents (e.g., potassium, LDH), altering lab results. Gentle mixing is recommended to prevent clotting without damaging cells, and immediate plasma separation plus correct storage temperature help preserve sample integrity rather than cause hemolysis. Therefore the collection method using too small a needle is the clear risk factor among the choices.

Question 48

A client is admitted to a burn unit with second- and third-degree burns over 18% of the body. An inhalation injury is also suspected. The nurse should monitor which of the following to determine the extent of carbon monoxide poisoning?

Accepted Answer

Answer reason: The most direct way to quantify exposure and severity is measuring carboxyhemoglobin percentage in the blood. Pulse oximetry is unreliable because it can read falsely normal/high in carbon monoxide poisoning. ABGs may show a normal PaO2 and do not measure carboxyhemoglobin unless co-oximetry is specifically used, so they do not best determine extent.

Question 49

A peak and trough level is ordered for a child who is scheduled to receive IV gentamicin at 0900. The medication is to infuse over 60 minutes. When should the nurse draw the peak level?

Accepted Answer

Answer reason: If gentamicin starts at 0900 and infuses over 60 minutes, the infusion ends at 1000. Drawing the specimen at 1030 captures the appropriate post-infusion peak timing. A sample immediately before the infusion is a trough (to assess accumulation/toxicity risk), and routine early-morning labs are not reliably timed to the dose for therapeutic drug monitoring.

Question 50

The nurse prepares a client for a positron emission tomography (PET) scan. Which laboratory data is necessary to obtain before this test?

Accepted Answer

Answer reason: PET scans commonly use 18F-fluorodeoxyglucose (FDG), and serum glucose levels directly affect tracer uptake and image quality. Hyperglycemia competes with FDG for cellular uptake, causing reduced lesion conspicuity and potentially false-negative results. Checking blood glucose beforehand allows safe and accurate timing or rescheduling and is especially important in clients with diabetes. The other labs listed are not routinely required for PET itself because it does not rely on iodinated contrast nephrotoxicity screening or hepatic metabolism monitoring.

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