2) A 78-year-old male client needs to complete a 24-hour urine specimen. In planning his
care, the nurse realizes that which measure is most important?
1. Instruct the client to empty his bladder and save this voiding to start the collection.
2. Instruct the client to use sterile individual containers to collect the urine.
3. Post a sign stating "Save All Urine" in the bathroom.
4. Keep the urine specimen in the refrigerator. - ANSWER Answer: 3. Rationale: Option 3
is the most important nursing measure. This will inform the staff that the client is on a 24-
hour urine collection. Option 1 is not appropriate since the first voided specimen is to be
discarded. Option 2 is not an appropriate nursing measure since the specimen container is
clean not sterile, and one container is needed—not individual containers. Option 4 is
inappropriate because some 24-hour urine collections do not require refrigeration. Cognitive
Level: Understanding. Client Need: Physiological Integrity.Nursing Process: Implementation.
Learning Outcome: 34-6.
1) The nurse would call the primary care provider immediately for which laboratory result?
1. Hgb = 16 g/dL for a male client
2. Hct = 22% for a female client
3. WBC = 9 × 103/mL3
4. Platelets = 300 × 103/mL3 - ANSWER Answer: 2. Rationale: Option 2 is very low and
can lead to death. The client's red blood cells participate in oxygenation. Options 1, 3, and 4
are within normal range and should not be reported to the primary care provider. Cognitive
Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation.
Learning Outcome: 34-3.
3) The client has a urinary health problem. Which procedure is performed using indirect
visualization?
1. Intravenous pyelography (IVP)
2. Kidneys, ureter, bladder (KUB)
1
,3. Retrograde pyelography
4. Cystoscopy - ANSWER Answer: 2. Rationale: A KUB is an x-ray of the kidneys, ureters,
and bladder. This does not require direct visualization. Option 1 is an IVP, an intravenous
pyelogram, which requires the injection of a contrast media. Option 3 is a retrograde
pyelography, which requires the injection of a contrast media. Option 4 is a cystoscopy,
which uses a lighted instrument (cystoscope) inserted through the urethra, resulting in direct
visualization. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing
Process: Assessment. Learning Outcome: 34-8
4) Which noninvasive procedure provides information about the physiology or function of an
organ?
1. Angiography
2. Computerized tomography (CT)
3. Magnetic resonance imaging (MRI)
4. Positron emission tomography (PET) - ANSWER Answer: 4. Rationale: This type of
nuclear scan demonstrates the ability of tissues to absorb the chemical to indicate the
physiology and function of an organ. Option 1 is an invasive procedure that focuses on blood
flow through an organ. Options 2 and 3 provide information about density of tissue to help
distinguish between normal and abnormal tissue of an organ. Cognitive Level:
Remembering. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning
Outcome: 34-9
6) During an assessment, the nurse learns that the client has a history of liver disease. Which
diagnostic tests might be indicated for this client? Select all that apply.
1. Alanine aminotransferase (ALT)
2. Myoglobin
3. Cholesterol
4. Ammonia
5. Brain natriuretic peptide or B-type natriuretic peptide (BNP) - ANSWER Answer: 1 and
4. Rationale: ALT is an enzyme that contributes to protein and carbohydrate metabolism. An
increase in the enzyme indicates damage to the liver. The liver contributes to the
metabolism of protein, which results in the production of ammonia. If the liver is damaged,
the ammonia level is increased. Options 2, 3, and 5 (myoglobin, cholesterol, and BNP) are
2
, relevant for heart disease. Cognitive Level: Applying. Client Need: Physiological Integrity.
Nursing Process: Assessment. Learning Outcome: 34-2.
5) When assisting with a bone marrow biopsy, the nurse should take which action?
1. Assist the client to a right side-lying position after the
procedure.
2. Observe for signs of dyspnea, pallor, and coughing.
3. Assess for bleeding and hematoma formation for several days after the procedure.
4. Stand in front of the client and support the back of the neck and knees. - ANSWER
Answer: 3. Rationale: Bone marrow aspiration includes deep penetration into soft tissue and
large bones such as the sternum and iliac crest. This penetration can result in bleeding. The
client should be observed for bleeding in the days following the procedure. Option 1 is a
nursing action during a liver biopsy. Option 2 is a nursing action for a thoracentesis, and
Option 4 is a nursing action for a lumbar puncture. Cognitive Level: Applying. Client Need:
Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 34-10
7) The nurse practitioner requests a laboratory blood test to determine how well a client has
controlled her diabetes during the past 3 months. Which blood test will provide this
information?
1. Fasting blood glucose
2. Capillary blood specimen
3. Glycosylated hemoglobin
4. GGT (gamma-glutamyl transferase) - ANSWER Answer: 3. Rationale: A glycosylated
hemoglobin will indicate the glucose levels for a period of time, which is indicated by the
nurse practitioner. Options 1 and 2 will provide information about the current blood glucose,
not the past history. Option 4 is used to assess for liver disease. Cognitive Level:
Remembering. Client Need: Physiological
Integrity. Nursing Process: Planning. Learning Outcome: 34-2
8) The client is supposed to have a fecal occult blood test done on a stool sample. The nurse
is going to use the Hemoccult test. Which of the following indicates that the nurse is using
the correct procedure? Select all that apply.
3
care, the nurse realizes that which measure is most important?
1. Instruct the client to empty his bladder and save this voiding to start the collection.
2. Instruct the client to use sterile individual containers to collect the urine.
3. Post a sign stating "Save All Urine" in the bathroom.
4. Keep the urine specimen in the refrigerator. - ANSWER Answer: 3. Rationale: Option 3
is the most important nursing measure. This will inform the staff that the client is on a 24-
hour urine collection. Option 1 is not appropriate since the first voided specimen is to be
discarded. Option 2 is not an appropriate nursing measure since the specimen container is
clean not sterile, and one container is needed—not individual containers. Option 4 is
inappropriate because some 24-hour urine collections do not require refrigeration. Cognitive
Level: Understanding. Client Need: Physiological Integrity.Nursing Process: Implementation.
Learning Outcome: 34-6.
1) The nurse would call the primary care provider immediately for which laboratory result?
1. Hgb = 16 g/dL for a male client
2. Hct = 22% for a female client
3. WBC = 9 × 103/mL3
4. Platelets = 300 × 103/mL3 - ANSWER Answer: 2. Rationale: Option 2 is very low and
can lead to death. The client's red blood cells participate in oxygenation. Options 1, 3, and 4
are within normal range and should not be reported to the primary care provider. Cognitive
Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation.
Learning Outcome: 34-3.
3) The client has a urinary health problem. Which procedure is performed using indirect
visualization?
1. Intravenous pyelography (IVP)
2. Kidneys, ureter, bladder (KUB)
1
,3. Retrograde pyelography
4. Cystoscopy - ANSWER Answer: 2. Rationale: A KUB is an x-ray of the kidneys, ureters,
and bladder. This does not require direct visualization. Option 1 is an IVP, an intravenous
pyelogram, which requires the injection of a contrast media. Option 3 is a retrograde
pyelography, which requires the injection of a contrast media. Option 4 is a cystoscopy,
which uses a lighted instrument (cystoscope) inserted through the urethra, resulting in direct
visualization. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing
Process: Assessment. Learning Outcome: 34-8
4) Which noninvasive procedure provides information about the physiology or function of an
organ?
1. Angiography
2. Computerized tomography (CT)
3. Magnetic resonance imaging (MRI)
4. Positron emission tomography (PET) - ANSWER Answer: 4. Rationale: This type of
nuclear scan demonstrates the ability of tissues to absorb the chemical to indicate the
physiology and function of an organ. Option 1 is an invasive procedure that focuses on blood
flow through an organ. Options 2 and 3 provide information about density of tissue to help
distinguish between normal and abnormal tissue of an organ. Cognitive Level:
Remembering. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning
Outcome: 34-9
6) During an assessment, the nurse learns that the client has a history of liver disease. Which
diagnostic tests might be indicated for this client? Select all that apply.
1. Alanine aminotransferase (ALT)
2. Myoglobin
3. Cholesterol
4. Ammonia
5. Brain natriuretic peptide or B-type natriuretic peptide (BNP) - ANSWER Answer: 1 and
4. Rationale: ALT is an enzyme that contributes to protein and carbohydrate metabolism. An
increase in the enzyme indicates damage to the liver. The liver contributes to the
metabolism of protein, which results in the production of ammonia. If the liver is damaged,
the ammonia level is increased. Options 2, 3, and 5 (myoglobin, cholesterol, and BNP) are
2
, relevant for heart disease. Cognitive Level: Applying. Client Need: Physiological Integrity.
Nursing Process: Assessment. Learning Outcome: 34-2.
5) When assisting with a bone marrow biopsy, the nurse should take which action?
1. Assist the client to a right side-lying position after the
procedure.
2. Observe for signs of dyspnea, pallor, and coughing.
3. Assess for bleeding and hematoma formation for several days after the procedure.
4. Stand in front of the client and support the back of the neck and knees. - ANSWER
Answer: 3. Rationale: Bone marrow aspiration includes deep penetration into soft tissue and
large bones such as the sternum and iliac crest. This penetration can result in bleeding. The
client should be observed for bleeding in the days following the procedure. Option 1 is a
nursing action during a liver biopsy. Option 2 is a nursing action for a thoracentesis, and
Option 4 is a nursing action for a lumbar puncture. Cognitive Level: Applying. Client Need:
Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 34-10
7) The nurse practitioner requests a laboratory blood test to determine how well a client has
controlled her diabetes during the past 3 months. Which blood test will provide this
information?
1. Fasting blood glucose
2. Capillary blood specimen
3. Glycosylated hemoglobin
4. GGT (gamma-glutamyl transferase) - ANSWER Answer: 3. Rationale: A glycosylated
hemoglobin will indicate the glucose levels for a period of time, which is indicated by the
nurse practitioner. Options 1 and 2 will provide information about the current blood glucose,
not the past history. Option 4 is used to assess for liver disease. Cognitive Level:
Remembering. Client Need: Physiological
Integrity. Nursing Process: Planning. Learning Outcome: 34-2
8) The client is supposed to have a fecal occult blood test done on a stool sample. The nurse
is going to use the Hemoccult test. Which of the following indicates that the nurse is using
the correct procedure? Select all that apply.
3
