Question 1

The nurse is caring for a patient who is undergoing a liver biopsy. Which interventions will be included in the patient's care plan for the diagnosis of Risk for infection: r/t invasive diagnostic procedure? (Select all that apply.)
A) Monitor for and report redness, warmth, discharge, or fever promptly to the physician.
B) Carefully maintain the sterile field during the biopsy procedure.
C) Teach patient how to care for the biopsy site when procedure is completed.
D) Provide a supportive, caring presence to minimize patient anxiety.
E) Provide information about the pathophysiology and treatment options for liver cancer.
F) Consider using healing touch and other mind-body-spirit interventions.

Accepted Answer

Interventions for the nursing diagnosis of Risk for infection involve monitoring for signs and symptoms of infection, preventing contamination of supplies by maintaining a sterile field during the procedure, and teaching the patient how to care for the site afterward. Providing a caring presence, providing information about liver cancer, and using healing touch may be helpful for the patient but will not minimize the risk of infection.

Question 2

The nurse is caring for a patient who needs to collect a 24-hour urine specimen at home. Which steps of specimen collection may be delegated to the assistant? (Select all that apply.)
A) Label the urine container and lab slips with the patient's name and information.
B) Assess the patient's ability to collect the specimen as required.
C) Explain the procedure to the patient.
D) Obtain the urine container from the utility room or laboratory.
E) Transport the specimen to the laboratory once it is collected.
F) Ensure that the correct test is ordered and collected.

Accepted Answer

The assistant may label the container and lab slips, obtain the urine container from the utility room, and transport the specimen to the lab. These are tasks that do not require nursing judgment. Assessment of the patient is always done by the nurse, as well as explaining the procedure to the patient and ensuring that the correct test is performed.

Question 3

The nurse is caring for a patient who is anemic. Which CBC test results demonstrate that the patient's treatment plan is effective and the anemia is resolving? (Select all that apply.) 
A) Red blood cell count (RBC) 5.8 million/mm$^{3}$
B) Hematocrit (HCT) 25% 
C) Hemoglobin (HGB) 14 g/dL 
D) White blood cell count (WBC) 4500/mm$^{3}$ 
E) Platelet count (PLT) 255,000/mm$^{3}$

Accepted Answer

Red blood cell count of 5.8 million and hemoglobin value of 14 g/dL are both normal. Hematocrit level of 25% is very low and indicative of ongoing anemia. White blood cell and platelet counts are not checked for anemia.

Question 4

The nurse is caring for a patient who has been having abdominal pain. The doctor suspects that the patient may have an abdominal aortic aneurysm. Which tests would confirm the doctor's suspicion? (Select all that apply.)
A) Magnetic resonance imaging (MRI) scan
B) Needle aspiration with biopsy
C) Fiberoptic endoscopy
D) Computed tomography (CT) scan
E) Flexible sigmoidoscopy
F) Thoracentesis

Accepted Answer

CT scan and MRI may be used to determine the presence of an abdominal aortic aneurysm. Endoscopy, needle aspiration, sigmoidoscopy, and thoracentesis will not help make this diagnosis.

Question 5

The nurse is caring for a patient who is taking medication that is toxic to the liver. Which laboratory test results will be reviewed by the nurse to ensure that the patient's liver is tolerating the medication without damage to the organ? (Select all that apply.)
A) Alanine aminotransferase (ALT)
B) Alkaline phosphatase (ALP)
C) Blood urea nitrogen (BUN)
D) Anti-nuclear antibody (ANA)
E) Erythrocyte sedimentation rate (ESR)
F) Fibrin degradation products (FDP)

Accepted Answer

Alanine aminotransferase (ALT) and alkaline phosphatase (ALP) are indicators of liver function, and increased levels indicate liver damage from a variety of causes. BUN, ANA, ESR, and FDP are not indicators of liver function.

Quiz 34: Diagnostic Testing

The nurse is caring for a patient who is undergoing a liver biopsy. Which interventions will be included in the patient's care plan for the diagnosis of Risk for infection: r/t invasive diagnostic procedure? (Select all that apply.)

The nurse is caring for a patient who needs to collect a 24-hour urine specimen at home. Which steps of specimen collection may be delegated to the assistant? (Select all that apply.)

The nurse is caring for a patient who is anemic. Which CBC test results demonstrate that the patient's treatment plan is effective and the anemia is resolving? (Select all that apply.)

The nurse is caring for a patient who has been having abdominal pain. The doctor suspects that the patient may have an abdominal aortic aneurysm. Which tests would confirm the doctor's suspicion? (Select all that apply.)

The nurse is caring for a patient who is taking medication that is toxic to the liver. Which laboratory test results will be reviewed by the nurse to ensure that the patient's liver is tolerating the medication without damage to the organ? (Select all that apply.)