NCLEX Review
Adult Health
~ 52 Selected Lab & Diagnostic
Tests Questions
Nursing Considerations & Safety
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Questions and
Answers
1. A client’s laboratory results reveal a hemoglobin of 6 g/dL.
Which foods should be encouraged for this client?
A.
B.
C.
D.
Broiled fish
Whole grains
Dried fruits
Steamed vegetables
1. A client’s laboratory results reveal a hemoglobin of 6 g/dL.
Which foods should be encouraged for this client?
A.
B.
C.
D.
Broiled fish
Whole grains
Dried fruits
Steamed vegetables
C. With a low hemoglobin, the oxygen-carrying capacity of
the blood is diminished resulting in client fatigue. The
preserving agent for dried fruits adds iron, making the
fruits excellent sources for this mineral.
Normal Hgb range ~ 14-17 g/dl
2. Which nursing diagnosis is most appropriate for a female adult
client with a hemoglobin of 12.0 mg/dL and a hematocrit of
29%?
A.
B.
C.
D.
Fluid volume excess
Decreased tissue perfusion
Impaired tissue integrity
Risk for activity intolerance
2. Which nursing diagnosis is most appropriate for a female adult
client with a hemoglobin of 12.0 mg/dL and a hematocrit of
29%?
A.
B.
C.
D.
Fluid volume excess
Decreased tissue perfusion
Impaired tissue integrity
Risk for activity intolerance
A. Hemoglobin is normal. Hematocrit should be 3 times
the hemoglobin. If it is less than that, it indicates over
hydration or hemodilution.
Normal Hgb range ~ 14-17 g/dl
Normal Hct ~ 36-50% (males higher than females)
3. The reticulocyte count is elevated in a client with recent blood
loss due to severe skin laceration. In planning care, the RN
anticipates which physician order?
A.
B.
C.
D.
Maintain fluid intake at 2-3 liters per day
Obtain consent for bone marrow biopsy
Institute iron restricted diet
Prepare client for plasmaphoresis
3. The reticulocyte count is elevated in a client with recent blood
loss due to severe skin laceration. In planning care, the RN
anticipates which physician order?
A.
B.
C.
D.
Maintain fluid intake at 2-3 liters per day
Obtain consent for bone marrow biopsy
Institute iron restricted diet
Prepare client for plasmaphoresis
A. Increased reticulocyte count is normal after blood loss
or in anemia. It indicates the bone marrow is working to
replace lost RBCs by producing immature RBCs and
sending them into the circulation.
4. Which statement would be true of platelets?
A.
B.
C.
D.
Are formed and stored in the spleen
Repair damage to small blood vessels
Cause red blood cells to clump forming clots
Circulate for 4-6 weeks before dying
4. Which statement would be true of platelets?
A.
B.
C.
D.
Are formed and stored in the spleen
Repair damage to small blood vessels
Cause red blood cells to clump forming clots
Circulate for 4-6 weeks before dying
B. Platelets repair damage to small blood vessels. They
are formed in the bone marrow but are stored in the
spleen and clump together to form clots. They live 1-2
weeks.
Normal count = 150,000-450,000
5. Which is an explanation for a shift-to-the-left in the neutrophil
count?
A. Stem cells are being over produced
B. Bone marrow is releasing fewer mature cells into the
circulating blood
C. Bone marrow is responding to overproduction of
lymphocytes
D. The thymus gland is unable to produce T-cells
5. Which is an explanation for a shift-to-the-left in the neutrophil
count?
A. Stem cells are being over produced
B. Bone marrow is releasing fewer mature cells into the
circulating blood
C. Bone marrow is responding to overproduction of
lymphocytes
D. The thymus gland is unable to produce T-cells
B. This is the only response related to neutrophil shift-to-theleft.
6. Which of these clients should the nurse assess first?
A.
B.
C.
D.
Hemoglobin level of 15.9 g/dL
Coumadin with a prothrombin time (PT) of 35.6 seconds
Total calcium level of 9.4 mg/dL
BUN of 30 mg/dL and creatinine of 1.1 mg/dL
6. Which of these clients should the nurse assess first?
A.
B.
C.
D.
Hemoglobin level of 15.9 g/dL
Coumadin with a prothrombin time (PT) of 35.6 seconds
Total calcium level of 9.4 mg/dL
BUN of 30 mg/dL and creatinine of 1.1 mg/dL
B. Normal prothrombin time is <13 seconds and on coumadin
therapy, it should be 1.5-2.5 times greater. This client has
3 times greater time and so is at risk.
Normal Ca++ ` 9-10.5 mg / dl
Normal BUN ~ 7-20 mg / dl
Normal Creat ~ 0.5-1.5 mg/dl
7. Which client is most likely to have an elevated erythrocyte
sedimentation rate?
A.
B.
C.
D.
Congestive heart failure
Glaucoma
Hypertension
Pregnancy
7. Which client is most likely to have an elevated erythrocyte
sedimentation rate?
A.
B.
C.
D.
Congestive heart failure
Glaucoma
Hypertension
Pregnancy
D. This is the only correct answer.
^ ESR ~ inflammation
8. Which does not specifically increase HDL cholesterol levels?
A.
B.
C.
D.
Smoking cessation
Nicotinic acid
Lipitor (atorvastatin)
Exercise
8. Which does not specifically increase HDL cholesterol levels?
A.
B.
C.
D.
Smoking cessation
Nicotinic acid
Lipitor (atorvastatin)
Exercise
C. Lipitor decreases LDL and triglycerides. Stopping
smoking, nicotinic acid or niacin, and exercise raise HDL
levels.
9. After receiving report of four clients at 7:00 a.m., which
task should the nurse complete first?
A. Call physician to request antiemetic for client who has been
vomiting
B. Notify family of a client’s transfer to ICU for chest pain
C. Call a potassium level of 5.9 to the attention of the
physician
D. Begin routine assessment rounds, starting with the sickest
client
9. After receiving report of four clients at 7:00 a.m., which
task should the nurse complete first?
A. Call physician to request antiemetic for client who has been
vomiting
B. Notify family of a client’s transfer to ICU for chest pain
C. Call a potassium level of 5.9 to the attention of the
physician
D. Begin routine assessment rounds, starting with the sickest
client
C. A potassium level of 5.9 is life threatening.
normal serum K+ = 3.5-5.5
10.The nurse is reviewing laboratory test results for a client with
severe crush injuries of both lower extremities secondary to a
motor vehicle accident. Which result causes the nurse the
most concern?
A.
B.
C.
D.
Blood urea nitrogen of 18 mg/dL
Serum creatinine level of 1.2 mg/dL
White blood cell count of 9000/cu mm
Serum potassium of 6.0 mEq/dL
10.The nurse is reviewing laboratory test results for a client with
severe crush injuries of both lower extremities secondary to a
motor vehicle accident. Which result causes the nurse the
most concern?
A.
B.
C.
D.
Blood urea nitrogen of 18 mg/dL
Serum creatinine level of 1.2 mg/dL
White blood cell count of 9000/cu mm
Serum potassium of 6.0 mEq/dL
D. Hyperkalemia can lead to serious cardiac dysrhythmias
such as ventricular fibrillation or cardiac standstill. The
other lab values are within acceptable parameters.
normal serum K+ = 3.5-5.5
Normal WBC Count ~4300 to 10800
Normal BUN ~ 7-20 mg / dl
Normal Creat ~ 0.5-1.5 mg/dl
11. A 27-year-old construction worker is admitted to the Urgent
Care Center with tachycardia, hypotension, weakness,
decreased DTRs, headache, and agitation. The client’s skin
is moist and warm, the urine specific gravity is 1.030, and
loose stools have occurred. The outside temperature is 98o F
(36.67o C) and the client has consumed 1.5 liters of water in
the last 30 minutes. What is the most likely cause of the
symptoms?
A. Hypokalemia
B. Hyponatremia
C. Hypercalcemia
D. Hypomagnesemia
11. A 27-year-old construction worker is admitted to the Urgent
Care Center with tachycardia, hypotension, weakness,
decreased DTRs, headache, and agitation. The client’s skin
is moist and warm, the urine specific gravity is 1.030, and
loose stools have occurred. The outside temperature is 98o F
(36.67o C) and the client has consumed 1.5 liters of water in
the last 30 minutes. What is the most likely cause of the
symptoms?
A. Hypokalemia
Normal SG~ 1.002 and 1.035
B. Hyponatremia
C. Hypercalcemia
D. Hypomagnesemia
B. With heat, excessive sweating produces sodium and water
loss. The water consumed has no electrolytes and the
symptoms are consistent with hyponatremia and hypovolemia.
12. A client with a calcium level of 12.1 mg/dL is at risk for
which problem?
A.
B.
C.
D.
Renal calculi
Osteoporosis
Dental caries
Rickets
12. A client with a calcium level of 12.1 mg/dL is at risk for
which problem?
A.
B.
C.
D.
Renal calculi
Osteoporosis
Dental caries
Rickets
A. This is an elevated level of calcium and may contribute to
the formation of kidney stones.
Normal Ca++ ` 9-10.5 mg / dl
13. Major trauma to skeletal muscle tissue would not cause an
increase in which lab value?
A.
B.
C.
D.
Alkaline phosphatase
CK-MM
LDH
AST
13. Major trauma to skeletal muscle tissue would not cause an
increase in which lab value?
A.
B.
C.
D.
Alkaline phosphatase
CK-MM
LDH
AST
A. Alkaline phosphatase increases with bone trauma. The other
values increase with muscle trauma or necrosis.
14. A voided urinalysis result shows numerous epithelial cells,
bacteria, and leukocytes, but all other indices are normal.
Which intervention is appropriate at this time?
A.
B.
C.
D.
Notify the physician as this indicates an infection
Assess for allergy to antibiotics
Obtain a 2nd urinalysis using a clean-catch method
Perform a catheterized urinalysis
14. A voided urinalysis result shows numerous epithelial cells,
bacteria, and leukocytes, but all other indices are normal.
Which intervention is appropriate at this time?
A.
B.
C.
D.
Notify the physician as this indicates an infection
Assess for allergy to antibiotics
Obtain a 2nd urinalysis using a clean-catch method
Perform a catheterized urinalysis
C. This is most likely a contaminated specimen without proper
cleansing before collection.
15. A client is admitted for a cholecystectomy with a creatinine
level of 1.0 mg/dL and BUN of 22 mg/dL. Which medication
order would the nurse question?
A.
B.
C.
D.
Demerol 50 mg IM every 3-4 hours PRN severe pain
Glucophage (metformin) 500 mg PO every day
Carafate (sucralfate) 1 gm PO qid 1 hour ac and hs
Lopressor (metoprolol) 100 mg PO every day
15. A client is admitted for a cholecystectomy with a creatinine
level of 1.0 mg/dL and BUN of 22 mg/dL. Which medication
order would the nurse question?
A.
B.
C.
D.
Demerol 50 mg IM every 3-4 hours PRN severe pain
Glucophage (metformin) 500 mg PO every day
Carafate (sucralfate) 1 gm PO qid 1 hour ac and hs
Lopressor (metoprolol) 100 mg PO every day
B. Glucophage can lead to liver failure if the client goes into
metabolic acidosis (related to renal compromise).
16. The nurse is completing the admission history of a client who
is to undergo an intravenous pyelogram (IVP). Which client
statement would be cause for concern?
A. “I received penicillin as a child and it has made me sick ever
since.”
B. “I had a bad experience after eating seafood last year, so I
avoid it.”
C. “My doctor says I shouldn’t eat eggs because they can help
clog my arteries.”
D. “The last time I had a special test, there was a salty taste
when they gave me the dye.”
16. The nurse is completing the admission history of a client who
is to undergo an intravenous pyelogram (IVP). Which client
statement would be cause for concern?
A. “I received penicillin as a child and it has made me sick ever
since.”
B. “I had a bad experience after eating seafood last year, so I
avoid it.”
C. “My doctor says I shouldn’t eat eggs because they can help
clog my arteries.”
D. “The last time I had a special test, there was a salty taste
when they gave me the dye.”
B. Iodine-containing contrast media may be used for the IVP.
Many people who are allergic to seafood, are allergic to
iodine. If this allergy is present, an anaphylactic reaction
can occur during the IVP.
***also, think about oral hypoglycemics…
17. The client asks the nurse about special preparation for an
ultrasound of the kidneys. Which response by the nurse is most
appropriate?
A. “Radiopaque dye will be used to help visualize the kidney.”
B. “The puncture site will be monitored frequently for
bleeding.”
C. “No special preparation is required for this test.”
D. “There will be no food or fluid for 12 hours prior to the test.”
17. The client asks the nurse about special preparation for an
ultrasound of the kidneys. Which response by the nurse is most
appropriate?
A.
B.
C.
D.
“Radiopaque dye will be used to help visualize the kidney.”
“The puncture site will be monitored frequently for bleeding.”
“No special preparation is required for this test.”
“There will be no food or fluid for 12 hours prior to the test.”
C. An ultrasound exam is a noninvasive test that, in most cases,
requires no special preparation except a full bladder.
18. A 43-year-old anxious client is to receive teaching prior to a
cystoscopy. Which part of the teaching plan indicates the
need for clarification prior to talking to the client?
A. Assess client understanding of the procedure before
witnessing the consent form
B. Teach client that general anesthesia will likely be used
C. Client may have only clear liquids the evening before the
procedure
D. A bowel prep with laxatives will be completed before the
procedure
18. A 43-year-old anxious client is to receive teaching prior to a
cystoscopy. Which part of the teaching plan indicates the
need for clarification prior to talking to the client?
A. Assess client understanding of the procedure before
witnessing the consent form
B. Teach client that general anesthesia will likely be used
C. Client may have only clear liquids the evening before the
procedure
D. A bowel prep with laxatives will be completed before the
procedure
C. The client may have a light evening meal, then will be NPO
after midnight if general anesthesia is used.
19. After cystoscopy, the RN monitors the client for development
of post-procedural complications. Which symptom would be
most expected?
A.
B.
C.
D.
Urinary frequency and dysuria
Hypertension and polydipsia
Hematuria and hypotension
Orange discoloration to urine and bladder spasm
19. After cystoscopy, the RN monitors the client for development
of post-procedural complications. Which symptom would be
most expected?
A.
B.
C.
D.
Urinary frequency and dysuria
Hypertension and polydipsia
Hematuria and hypotension
Orange discoloration to urine and bladder spasm
A. The most common complication is urinary tract infection due to
instrumentation in the procedure.
20. A client with a goiter has a TSH of 0.3 mU/L. The RN would
expect which symptoms?
A.
B.
C.
D.
Weight gain, fatigue and bradycardia
Headache, diplopia and tinnitis
Bruit upon auscultation of thyroid and hypertension
Hypernatremia and decreased urine specific gravity
20. A client with a goiter has a TSH of 0.3 mU/L. The RN would
expect which symptoms?
A.
B.
C.
D.
Weight gain, fatigue and bradycardia
Headache, diplopia and tinnitis
Bruit upon auscultation of thyroid and hypertension
Hypernatremia and decreased urine specific gravity
C. Bruits are often heard with goiter and the hyperthyroidism
causes increase in systolic blood pressure and decrease in
thyroid stimulating hormone (TSH). A is hypothyroidism.
Normal TSH is 0.4-4.2 mU/L.
21. A client with hypothyroidism is on hormone replacement.
Which is true concerning abnormal TSH levels?
A. As the T3 and T4 levels drop, TSH also decreases as a
result of the positive feedback loop
B. After initiation of Synthroid (levothyroxine) the TSH level
decreases gradually as a result of the negative feedback
loop
C. Synthroid (levothyroxine) works primarily by converting T3
into T4 and as blood levels rise, TSH levels drop
D. As the TSH level rises after treatment is started with
Synthroid (levothyroxine), calcitonin levels rise and thyroid
function normalizes
21. A client with hypothyroidism is on hormone replacement.
Which is true concerning abnormal TSH levels?
A. As the T3 and T4 levels drop, TSH also decreases as a
result of the positive feedback loop
B. After initiation of Synthroid (levothyroxine) the TSH level
decreases gradually as a result of the negative feedback
loop
C. Synthroid (levothyroxine) works primarily by converting T3
into T4 and as blood levels rise, TSH levels drop
D. As the TSH level rises after treatment is started with
Synthroid (levothyroxine), calcitonin levels rise and thyroid
function normalizes
B. This is the only true statement.
22. Which client could have a thyroid scan?
A.
B.
C.
D.
Allergic to shellfish and betadine
24 weeks pregnant
Breastfeeding a 6 week old baby
Completed steroid treatment 3 weeks ago
22. Which client could have a thyroid scan?
A.
B.
C.
D.
Allergic to shellfish and betadine
24 weeks pregnant
Breastfeeding a 6 week old baby
Completed steroid treatment 3 weeks ago
D. Radioactive iodine may be used 21 days after discontinuing
corticosteroids.
23. A 43-year-old obese female client has a fasting blood sugar
of 140 mg/dL and states her blood glucose has never been
elevated before. Which is the top priority?
A.
B.
C.
D.
Potential for hypoglycemia
Risk for injury related to hyperglycemia
Knowledge deficit related to disease process
Potential for ineffective individual coping
23. A 43-year-old obese female client has a fasting blood sugar
of 140 mg/dL and states her blood glucose has never been
elevated before. Which is the top priority?
A.
B.
C.
D.
Potential for hypoglycemia
Risk for injury related to hyperglycemia
Knowledge deficit related to disease process
Potential for ineffective individual coping
C. Potential problems and risks are secondary priorities. The
client has an existing knowledge deficit related to this newly
diagnosed diabetes mellitus (FBS>126 mg/dL is diagnostic).
24. A 16-year-old client with type I Diabetes Mellitus is
sporadically non-compliant with diet and today’s FBS was 116
mg/dL. Which glycosylated hemoglobin would indicate a need
for more teaching?
A.
B.
C.
D.
Hgb A1C is 2.5%
Hgb A1C is 6.5%
Hgb A1C has increased from 5.9% to 7.9%
Hgb A1C has dropped from 4% to 2.5%
24. A 16-year-old client with type I Diabetes Mellitus is
sporadically non-compliant with diet and today’s FBS was 116
mg/dL. Which glycosylated hemoglobin would indicate a need
for more teaching?
A.
B.
C.
D.
Hgb A1C is 2.5%
Hgb A1C is 6.5%
Hgb A1C has increased from 5.9% to 7.9%
Hgb A1C has dropped from 4% to 2.5%
C. Normal Hgb A1C for a diabetic in good control is 6-7%. An
increase of 2% and over the normal indicates a need for
more teaching.
25. A pregnant client at 28 weeks gestation has a fasting 1 hour
glucose challenge test with a result of 156 mg/dL. Which
would be the best response by the nurse?
A.
B.
C.
D.
Tell her she has diabetes mellitus and plan teaching
Order a 3 hour glucose tolerance test per protocol
Continue to monitor her as this is normal
Continue to monitor the elevated placental lactogen
25. A pregnant client at 28 weeks gestation has a fasting 1 hour
glucose challenge test with a result of 156 mg/dL. Which
would be the best response by the nurse?
A.
B.
C.
D.
Tell her she has diabetes mellitus and plan teaching
Order a 3 hour glucose tolerance test per protocol
Continue to monitor her as this is normal
Continue to monitor the elevated placental lactogen
B. If the GCT is above 140 mg/dL, a 3 hour GTT is indicated.
Also, it should be done non-fasting.
26. The nurse is asked to collect a sample of exudate from a
client’s wound for a culture and sensitivity. What procedure
would be best?
A.
B.
C.
D.
Irrigate the wound and then collect sample
Place sample in sterile container for transport
Start the ordered antibiotic and then collect sample
Swab the skin around the wound to collect sample
26. The nurse is asked to collect a sample of exudate from a
client’s wound for a culture and sensitivity. What procedure
would be best?
A.
B.
C.
D.
Irrigate the wound and then collect sample
Place sample in sterile container for transport
Start the ordered antibiotic and then collect sample
Swab the skin around the wound to collect sample
B. All specimens must be collected using sterile methods and
placed in a sterile container. Antibiotics should be started
after specimen collection.
27. Which client would the nurse send for an MRI without
questioning the order?
A.
B.
C.
D.
Diabetic with an implanted insulin pump
Pregnant primigravida at 34 weeks gestation
Client with heart failure and a pacemaker
Auto accident victim on life support systems
27. Which client would the nurse send for an MRI without
questioning the order?
A.
B.
C.
D.
Diabetic with an implanted insulin pump
Pregnant primigravida at 34 weeks gestation
Client with heart failure and a pacemaker
Auto accident victim on life support systems
B. Pregnancy is not a contraindication for MRI. The other
options have equipment containing metal which would
cause the MRI equipment to malfunction.
28. Which consideration would be least important when a
client is to have computed tomography (CT) scan with
contrast medium?
A.
B.
C.
D.
Client has Huntington disease
Client has chronic renal failure
Client had hives following an IVP
Client ate lunch 5 hours ago
28. Which consideration would be least important when a
client is to have computed tomography (CT) scan with
contrast medium?
A.
B.
C.
D.
Client has Huntington disease
Client has chronic renal failure
Client had hives following an IVP
Client ate lunch 5 hours ago
D. Clients are usually NPO for no more than 4 hours before
the test. The client must lie still and must be able to clear
the contrast medium without reacting negatively to it.
29. What follow-up care is needed for a client with PAP
(Papanicolaou test) results of "atypical squamous cells of
undetermined significance“ (ASCUS)?
A. Normal report and requires no special follow-up
B. Indicates cancerous cells; client will have an immediate
colonoscopy
C. Abnormal report; client will need follow-up evaluation
D. Indicates cancerous cells; client will require a
hysterectomy
29. What follow-up care is needed for a client with PAP
(Papanicolaou test) results of "atypical squamous cells of
undetermined significance“ (ASCUS)?
A. Normal report and requires no special follow-up
B. Indicates cancerous cells; client will have an immediate
colonoscopy
C. Abnormal report; client will need follow-up evaluation
D. Indicates cancerous cells; client will require a hysterectomy
C. This is not a normal report and indicates that further
information is needed before a diagnosis of cancer is made.
30. A 42-year-old female client asks the RN when she should
have a mammogram. What is the RN’s best reply based on
current American Cancer Society recommendations?
A.
B.
C.
D.
“Have a baseline mammogram between age 40 and 45.”
“Begin having annual mammograms now.”
“Begin having annual mammograms at age 50.”
“Begin having mammograms every other year now.”
30. A 42-year-old female client asks the RN when she should
have a mammogram. What is the RN’s best reply based on
current American Cancer Society recommendations?
A.
B.
C.
D.
“Have a baseline mammogram between age 40 and 45.”
“Begin having annual mammograms now.”
“Begin having annual mammograms at age 50.”
“Begin having mammograms every other year now.”
B. According to the American Cancer Society, women should
begin having annual mammograms at age 40.
31. Which client statement indicates a need for further teaching
regarding a mammogram?
A. “I will not bathe on the morning of the procedure.”
B. “I will not apply deodorant before the procedure.”
C. “I will experience some discomfort from the compression of
the tissue during the procedure.”
D. “I will be asked to remove my clothing from the waist up
prior to this procedure.”
31. Which client statement indicates a need for further teaching
regarding a mammogram?
A. “I will not bathe on the morning of the procedure.”
B. “I will not apply deodorant before the procedure.”
C. “I will experience some discomfort from the compression of
the tissue during the procedure.”
D. “I will be asked to remove my clothing from the waist up
prior to this procedure.”
A. Clients may bathe before a mammogram. However, they
should be instructed not to wear lotions, powders, or
deodorants as these may contain metallic salts.
32. What is the rationale for including the step of inspection of the
breasts with the arms raised above the head when performing
breast self examination?
A.
B.
C.
D.
Facilitates inspection of axillary lymph nodes
Triggers spontaneous nipple discharge
Elevates nipple and areolar area
Reveals changes in breast contour and symmetry
32. What is the rationale for including the step of inspection of the
breasts with the arms raised above the head when performing
breast self examination?
A.
B.
C.
D.
Facilitates inspection of axillary lymph nodes
Triggers spontaneous nipple discharge
Elevates nipple and areolar area
Reveals changes in breast contour and symmetry
D. Changes in shape or contour are emphasized when the
arms are raised over the head.
33. How would the nurse best teach a client about an endometrial
biopsy?
A.
B.
C.
D.
Will require an overnight hospital stay
A tube will be inserted into the uterus through the abdomen
There will be cramping during the procedure
A magnifying instrument will allow tissue visualization
33. How would the nurse best teach a client about an endometrial
biopsy?
A.
B.
C.
D.
Will require an overnight hospital stay
A tube will be inserted into the uterus through the abdomen
There will be cramping during the procedure
A magnifying instrument will allow tissue visualization
C. There will be cramping when the biopsy is taken. The
procedure is done in an office or clinic by placing a tube
thru the cervix into the uterine body. Tissue is not
visualized.
34. A colposcopy is scheduled for a client. In reviewing the
client’s chart, which would the RN expect in the history?
A.
B.
C.
D.
History of infertility
History of abnormal PAP smear
Family history of ovarian cancer
History of cervical laceration
34. A colposcopy is scheduled for a client. In reviewing the
client’s chart, which would the RN expect in the history?
A.
B.
C.
D.
History of infertility
History of abnormal PAP smear
Family history of ovarian cancer
History of cervical laceration
B. Colposcopy is used to locate the exact site of precancerous
and malignant lesions for tissue biopsy following an
abnormal PAP smear.
35. A client had a laparoscopic tubal ligation this morning. Which
nursing diagnosis has the highest priority?
A.
B.
C.
D.
Pain related to CO2 insufflation
Activity intolerance related to post-anesthesia fatigue
Risk for infection related to surgical incision
Risk for altered tissue perfusion related to surgical
procedure
35. A client had a laparoscopic tubal ligation this morning. Which
nursing diagnosis has the highest priority?
A.
B.
C.
D.
Pain related to CO2 insufflation
Activity intolerance related to post-anesthesia fatigue
Risk for infection related to surgical incision
Risk for altered tissue perfusion related to surgical
procedure
A. Carbon dioxide gas is used to separate the internal
structures for better visualization and the remaining gas
stimulates the diaphragm resulting in left shoulder pain.
36. A teenage client who is scheduled for a lumbar
puncture, was told by friends that “the brain sinks” when
cerebrospinal fluid is removed. Choose the best
response by the nurse to lower anxiety levels.
A. “Removing the small amount of CSF during the
procedure has absolutely no effect on the brain.”
B. “The amount of CSF removed will be rapidly
replaced by the body.”
C. “The body has more fluid than is necessary and the
amount removed is insignificant.”
D. “The physician will monitor the CSF pressure closely
during the procedure to minimize any danger.”
36. A teenage client who is scheduled for a lumbar
puncture, was told by friends that “the brain sinks” when
cerebrospinal fluid is removed. Choose the best
response by the nurse to lower anxiety levels.
A. “Removing the small amount of CSF during the procedure has
absolutely no effect on the brain.”
B. “The amount of CSF removed will be rapidly replaced by the
body.”
C. “The body has more fluid than is necessary and the amount
removed is insignificant.”
D. “The physician will monitor the CSF pressure closely during
the procedure to minimize any danger.”
• Clarification of how the body works is reassuring to
the client.
37. Which statement would best assist a client to
prepare for a cerebral angiogram?
A. “This X-ray will help assess the circulation around your heart.”
B. “You will have a regular breakfast before the test.”
C. “A contrast dye will be injected to help visualize the blood
vessels.”
D. “The catheter will be inserted in your left arm close to the
heart.”
37. Which statement would best assist a client to prepare for
a cerebral angiogram?
A. “This X-ray will help assess the circulation around your heart.”
B. “You will have a regular breakfast before the test.”
C. “A contrast dye will be injected to help visualize the blood
vessels.”
D. “The catheter will be inserted in your left arm close to the
heart.”
• A contrast dye will be inserted through the
groin to visualize the vessels in the brain.
Clients are either NPO or have only clear
liquids 6-8 hours before the procedure.
38. Which statement would be representative of a
normal electrocardiogram (EKG)?
A.
B.
C.
D.
QRS complex of .08 seconds
PR interval of .05 seconds
P wave of .14 seconds
Total heart beat of 4 seconds
38. Which statement would be representative of a
normal electrocardiogram (EKG)?
A.
B.
C.
D.
QRS complex of .08 seconds
PR interval of .05 seconds
P wave of .14 seconds
Total heart beat of 4 seconds
• The normal QRS complex is .06-.10 seconds. PR
interval should be .12-.20 seconds and P wave
should be less than .11 seconds. The normal heart
beat is about .20-.40 seconds.
39. The nurse is reviewing laboratory tests of a
client who was admitted with chest pain. Which
result should the nurse report to the physician
immediately?
A. Elevation in serum troponin level
B. Decrease in serum troponin level
C. Elevation in blood urea nitrogen level
D. Decrease in serum creatinine level
39. The nurse is reviewing laboratory tests of a
client who was admitted with chest pain. Which
result should the nurse report to the physician
immediately?
• A.
B.
C.
D.
Elevation in serum troponin level
Decrease in serum troponin level
Elevation in blood urea nitrogen level
Decrease in serum creatinine level
• A. Cardiac troponin is virtually undetectable in the serum
of healthy people, but rises to a detectable level within 1
hour of myocardial injury. It is especially useful in the
early diagnosis of acute MI and in detection of “silent”
MI.
40. During a treadmill stress test, a middle-aged client
becomes extremely diaphoretic and complains of pressure
in the mid-chest. The nurse notes the ST segment is
elevated on the EKG. What is the nurse’s first action?
A. Offer a glass of cool water to help replace fluid lost by
sweating
B. Have the client take a break and give the morning dose of
digoxin (Lanoxin)
C. Continue the test at a slower rate and notify the physician
D. Stop the test, have the client sit or lie down and assess vital
signs
40. During a treadmill stress test, a middle-aged client
becomes extremely diaphoretic and complains of pressure
in the mid-chest. The nurse notes the ST segment is
elevated on the EKG. What is the nurse’s first action?
A. Offer a glass of cool water to help replace fluid lost by
sweating
B. Have the client take a break and give the morning dose of
digoxin (Lanoxin)
C. Continue the test at a slower rate and notify the physician
D. Stop the test, have the client sit or lie down and assess vital
signs
• D. These symptoms and EKG changes may
indicate the onset of an MI and any farther
activity will worsen the condition.
41. The nurse is teaching a client who is scheduled
for 24-hour Holter monitoring. Which client
statement indicates that the teaching was
successful?
A. “I should remain as still as possible while wearing the monitor.”
B. “I will keep a log of daily activities while I am wearing the
monitor.”
C. “I will avoid physical strain while I am wearing the monitor.”
D. “I will avoid using caffeine while wearing the monitor.”
41. The nurse is teaching a client who is scheduled for
24-hour Holter monitoring. Which client statement
indicates that the teaching was successful?
A. “I should remain as still as possible while wearing the
monitor.”
B. “I will keep a log of daily activities while I am wearing the
monitor.”
C. “I will avoid physical strain while I am wearing the
monitor.”
D. “I will avoid using caffeine while wearing the monitor.”
• B. The client should maintain a daily schedule as close to normal as
possible while wearing a Holter monitor, and should continue the
usual diet. It is important for the client to record all activities while
being monitored, for comparison of the activities with EKG tracings
during analysis of the data.
42. What statement would best describe an
echocardiogram?
A.
B.
C.
D.
Percussive tapping of the chest over the heart
Noninvasive ultrasound of the lungs
Invasive electroconduction examination
Sonographic examination of the heart
42. What statement would best describe an
echocardiogram?
A.
B.
C.
D.
Percussive tapping of the chest over the heart
Noninvasive ultrasound of the lungs
Invasive electroconduction examination
Sonographic examination of the heart
• D. Echocardiogram is a noninvasive ultrasound or
sonograph of the heart for visualization purposes.
43. Following cardiac catheterization, what nursing
diagnosis would be the most appropriate?
A.
B.
C.
D.
Risk for clot displacement
Risk for fluid volume deficit
Risk for situational fear
Risk for disturbed individual coping
43. Following cardiac catheterization, what nursing
diagnosis would be the most appropriate?
A.
B.
C.
D.
Risk for clot displacement
Risk for fluid volume deficit
Risk for situational fear
Risk for disturbed individual coping
• B. Bleeding at the site of catheter introduction is
a potential complication leading to fluid volume
deficit. Clot displacement is not a nursing
diagnosis
44. Which statement would be appropriate for a
pulmonary function test?
A. Residual volume is the maximum amount of air that can
be expired
B. Vital capacity is the amount of air left after expiration
C. Tidal volume is the amount of air exchanged
D. Pulmonary function may be used to diagnose early stage
lung cancer
44. Which statement would be appropriate for a
pulmonary function test?
A. Residual volume is the maximum amount of air that can be
expired
B. Vital capacity is the amount of air left after expiration
C. Tidal volume is the amount of air exchanged
D. Pulmonary function may be used to diagnose early stage lung
cancer
• C. This is the only correct statement.
45. A post-bronchoscopy client develops wheezing,
stridor, and becomes cyanotic. Identify the highest
priority nursing action.
A. Check the gag reflex to make sure the local anesthetic
has worn off
B. Call the client’s physician about the symptoms
C. Assess breath sounds and maintain the airway
D. Encourage the client to cough and deep-breathe to
reduce secretions
45. A post-bronchoscopy client develops wheezing,
stridor, and becomes cyanotic. Identify the highest
priority nursing action.
A. Check the gag reflex to make sure the local anesthetic
has worn off
B. Call the client’s physician about the symptoms
C. Assess breath sounds and maintain the airway
D. Encourage the client to cough and deep-breathe to
reduce secretions
• C. The client is developing respiratory distress from
irritation and swelling of the respiratory mucosa.
While all four measures may be appropriate nursing
actions, at this time assessing and maintaining the
airway have the highest priority.
46. Which instruction is appropriate when providing
education to the client who is scheduled for a
thoracentesis,?
A. “No eating or drinking will be allowed until your gag reflex
returns.”
B. “A feeling of pressure may be experienced during the
procedure.”
C. “Peripheral pulses will be assessed frequently following the
procedure.”
D. “Bedrest with the head elevated is required for 24 hours after
the procedure.”
46. Which instruction is appropriate when providing
education to the client who is scheduled for a
thoracentesis,?
A. “No eating or drinking will be allowed until your gag reflex
returns.”
B. “A feeling of pressure may be experienced during the
procedure.”
C. “Peripheral pulses will be assessed frequently following the
procedure.”
D. “Bedrest with the head elevated is required for 24 hours after
the procedure.”
• B. A feeling of pressure may occur when the physician inserts
the large-bore needle into the pleural space. Choices A, C and
D are not accurate.
47. A client is complaining of discomfort 1-2 hours after eating
with feelings of fullness. How might this best be assessed?
A.
B.
C.
D.
Jejunoscopy
Laparoscopy
Gastroscopy
Lower GI series
47. A client is complaining of discomfort 1-2 hours after eating
with feelings of fullness. How might this best be assessed?
A.
B.
C.
D.
Jejunoscopy
Laparoscopy
Gastroscopy
Lower GI series
• C. Gastroscopy is the direct visualization of
the stomach. Another possible assessment
would be an upper GI series.
48. The nurse is preparing a client for a colonoscopy scheduled
for the next morning. Select the physician order that would
require clarification.
A.
B.
C.
D.
Administration of a cleansing enema
Clear liquid diet the day before the procedure
Obtaining a client signature on a consent form
A regular breakfast ordered before the procedure
48. The nurse is preparing a client for a colonoscopy scheduled
for the next morning. Select the physician order that would
require clarification.
A.
B.
C.
D.
Administration of a cleansing enema
Clear liquid diet the day before the procedure
Obtaining a client signature on a consent form
A regular breakfast ordered before the procedure
• D. The other choices are appropriate orders prior to
a colonoscopy. Since the intestinal system is the
focus of this diagnostic procedure, it doesn’t make
sense for the client to have regular food prior to the
procedure.
49. What would be the best client position for a
sigmoidoscopy?
A.
B.
C.
D.
Left lateral Sims
Right lateral Sims
Knee-chest
Trendelenburg
49. What would be the best client position for a
sigmoidoscopy?
A. Left lateral Sims
B. Right lateral Sims
C. Knee-chest
D. Trendelenburg
• C. This is the correct position.
50. After paracentesis, all of the assessment data is
identified. On which should the RN focus the care first?
A.
B.
C.
D.
Hypotension and flushed skin
Eupnea and increased bowel sounds
Peripheral edema and thirst
Nausea and fatigue
50. After paracentesis, all of the assessment data is
identified. On which should the RN focus the care first?
A.
B.
C.
D.
Hypotension and flushed skin
Eupnea and increased bowel sounds
Peripheral edema and thirst
Nausea and fatigue
• A. These are symptoms of hypovolemia with
vasodilatation and shock and need immediate
attention. While the other symptoms will require
attention, they do not place the client in
immediate danger.
51. Which statement by the certified nursing assistant indicates
understanding of the correct procedure for obtaining a stool
specimen for culture and sensitivity?
A. “Apply a thin smear of the stool specimen to a guaiacimpregnated card.”
B. “A special preservative must be placed in the container with
the specimen.”
C. “I need to give a small enema to evacuate stool from the
bowel for collection.”
D. “A sterile container must be used for specimen collection.”
51. Which statement by the certified nursing assistant indicates
understanding of the correct procedure for obtaining a stool
specimen for culture and sensitivity?
A. “Apply a thin smear of the stool specimen to a guaiacimpregnated card.”
B. “A special preservative must be placed in the container with
the specimen.”
C. “I need to give a small enema to evacuate stool from the
bowel for collection.”
D. “A sterile container must be used for specimen collection.”
D. All specimens for culture and sensitivity must be placed in
sterile containers to eliminate the possibility of contamination
by outside organisms.
52. Which client statement about conscious sedation (moderate
sedation) for a colonoscopy indicates that teaching by the nurse
has been effective?
A. “After I receive the medicine, I’ll be ‘out like a light’ and will sleep soundly
through the whole procedure.”
B. “The medicine I’ll be given for this type of sedation is Stadol (butorphanol),
the same medicine I took for pain after my hernia operation.”
C. “I will need to be hospitalized the night before the colonoscopy to be
observed for any side effects to a test dose of the conscious sedation
medicine.”
D. “This kind of sedation will help me relax, so I can cooperate with the doctor
during the colonoscopy.”
52. Which client statement about conscious sedation (moderate
sedation) for a colonoscopy indicates that teaching by the nurse
has been effective?
A. “After I receive the medicine, I’ll be ‘out like a light’ and will sleep soundly
through the whole procedure.”
B. “The medicine I’ll be given for this type of sedation is Stadol (butorphanol),
the same medicine I took for pain after my hernia operation.”
C. “I will need to be hospitalized the night before the colonoscopy to be
observed for any side effects to a test dose of the conscious sedation
medicine.”
D. “This kind of sedation will help me relax, so I can cooperate with the doctor
during the colonoscopy.”
• D. Conscious sedation or “twilight sleep” facilitates decrease in anxiety
and promotes cooperation and relaxation. The protective airway reflexes
are maintained. Midazolam (Versed) is one agent commonly used for
conscious sedation.