Description

Identify the choice that best completes the statement or answers the question.

____ 1. A patient with a diagnosis of chronic myelogenous leukemia (CML) is admitted to an acute care unit with a temperature of 100.4°F (38°C) and weight loss over the past 2 to 3 months. A nurse notes that the patient’s white blood cell (WBC) count is 230,000/mm³, and the physical examination shows splenomegaly. The priority nursing intervention should be:

1)	Avoiding falls
2)	Managing pain
3)	Preventing infection
4)	Promoting adequate nutrition

____ 2. A patient with diabetes requires assessment of long-term glucose control. Which test would be most appropriate for this patient?

1)	Glycated hemoglobin
2)	Glucose
3)	Glucose-6-phosphate dehydrogenase (G6PD)
4)	Glucose tolerance test

____ 3. A nurse notes that a patient has a urine pH of 7.2. Which information in the patient’s history may be related to this result?

1)	Maintaining a vegetarian diet
2)	Training for a marathon
3)	Recent febrile illness
4)	Use of cranberry supplements daily

____ 4. A patient with pernicious anemia has a laboratory order to test for intrinsic factor (IF) antibodies. A nurse scheduling this test should instruct the patient to:

1)	Begin a bowel prep 24 hours prior to the examination.
2)	Eliminate red meat from the diet for 72 hours before the test.
3)	Take nothing by mouth for 12 hours before the test is scheduled.
4)	Withhold vitamin B12 for 48 hours before the test is scheduled.

____ 5. A nurse observes that a patient admitted to the emergency department with decreased level of consciousness has urine with a very fruity odor. Based on this observation, the nurse should plan interventions to manage:

1)	Alcohol withdrawal
2)	Diabetic ketoacidosis (DKA)
3)	Fibromyalgia
4)	Lyme disease

____ 6. A patient must undergo pulmonary angiography but has a history of allergic reaction to some medications. Which of the following actions should be taken in response to this finding?

1)	Remove all metallic objects from the area to be examined.
2)	Administer an antianxiety agent, as ordered.
3)	Use a nonionic contrast medium.
4)	Notify the health-care provider to cancel the procedure.

____ 7. A patient’s laboratory test results following amniotic fluid analysis indicate elevated a₁-fetoprotein (AFP) levels and presence of acetylcholinesterase (AChE). Which of the following diagnoses should the nurse most suspect given these findings?

1)	Respiratory distress syndrome
2)	Fetal hemolytic disease
3)	Neural tube defect
4)	Fetal immaturity

____ 8. A college student who is admitted to the hospital with newly diagnosed diabetes mellitus has a C-peptide level of 0.6 ng/mL and serum glucose of 256 mg/dL. Based on these results, which instruction should the nurse provide to this patient?

1)	“Based on these results, your diabetes will be controlled by oral medications and diet.”
2)	“If you lose weight, you may be able to manage your diabetes with diet alone.”
3)	“Since you are already an adult, this result confirms that you have type 2 diabetes.”
4)	“You will need to take insulin for the rest of your life.”

____ 9. Which laboratory test should a nurse monitor to determine if a patient is responding to the administration of iron for iron-deficiency anemia?

1)	Eosinophils
2)	Lymphocytes
3)	Monocytes
4)	Reticulocytes

____ 10. A patient with an indwelling urinary catheter has an order for a 24-hour urine creatinine clearance test. To begin the test, the nurse should:

1)	Collect all urine during any 24-hour period by labeling the drainage collection bag with the date and time most recently emptied.
2)	Clamp the urinary catheter and then drain all urine into the container specified by the lab and repeat every 6 hours times 4.
3)	Empty all urine in the urinary drainage bag at 0600 and then save all urine until the next day at 0600.
4)	Increase meat portions in the diet for at least 48 hours prior to the planned start of the collection.

____ 11. A nurse is preparing to perform a lumbar puncture to collect a specimen for diagnosis of Alzheimer’s disease. Which position should the nurse ask the patient to assume for this test?

1)	Knee-chest
2)	Sidelying
3)	Prone
4)	Standing

____ 12. Which blood tests should a nurse monitor to determine if a patient’s blood level of warfarin (Coumadin) is within the therapeutic range?

1)	Activated partial thromboplastin time (aPTT)
2)	Bleeding time
3)	Platelet count and aPTT
4)	PT and international normalized ratio (INR)

____ 13. A nurse has just conducted hearing loss audiometry testing on a 10-year-old patient. The patient’s pure tone average was 52 dB. Which category of hearing of the American Speech-Language-Hearing Association (ASHA) does this result represent?

1)	Normal
2)	Slight loss
3)	Moderate loss
4)	Profound loss

____ 14. A nurse has just administered an IV nucleotide to a patient before a gallium scan. The nurse should instruct the patient to return for the first scanning in how many hours, typically?

1)	6 hours
2)	24 hours
3)	48 hours
4)	72 hours

____ 15. A nurse notes that a patient’s laboratory results show an acetylcholine receptor antibody (AChR) of 2.46 nmol/L. Based on this information, the nurse should assess this patient for clinical manifestations of:

1)	Malignant hyperpraxia
2)	Myasthenia gravis
3)	Multiple myeloma
4)	Muscular dystrophy

____ 16. A patient is suspected of having increased risk for stroke. Which type of angiography should be performed to detect this condition?

1)	Abdominal
2)	Adrenal
3)	Carotid
4)	Coronary

____ 17. Which factor in a patient’s history may be associated with an elevated creatine phosphokinase (CK) level?

1)	Sedentary lifestyle
2)	Early muscular dystrophy
3)	Bedrest for 48 hours
4)	History of chronic renal failure

____ 18. A nurse is preparing to administer a radionuclide to an adult patient for a gastroesophageal reflux (GER) scan. What should the nurse mix the radionuclide with?

1)	Orange juice
2)	Milk
3)	Water
4)	Soda

____ 19. A patient is suspected of having multiple myeloma and needs to undergo testing to identify the individual types of immunoglobulins present to confirm a diagnosis. Which test would be most appropriate for this purpose?

1)	Immunofixation electrophoresis (IFE)
2)	Immunoglobulin E (IgE)
3)	Immunoglobulin A (IgA)
4)	Immunosuppressant cyclosporine

____ 20. A patient with a history of hypertension has a serum creatinine of 1.9 mg/dL and 1+ proteinuria. When assessing this patient, a nurse should interpret these results as an indication this patient may have:

1)	Early signs of renal insufficiency
2)	Evidence of severe renal dysfunction
3)	Hypertension secondary to renal disease
4)	Normal renal function

____ 21. A patient who is treated in an emergency department following a sexual assault is concerned about the possibility of infection with HIV. The patient requests a blood test to determine if HIV infection has occurred. The results are negative. Which action by the nurse is appropriate?

1)	Inform the patient to monitor for symptoms, since false-negative results are common.
2)	Instruct the patient to schedule a follow-up test in 6 months.
3)	Reassure the patient that no infection with HIV has occurred.
4)	Reinforce the need to use appropriate protection with intercourse in the future.

____ 22. A patient maintained on furosemide (Lasix) is admitted with a serum potassium level of 2.9 mEq/L. Which clinical manifestation should the nurse expect to find on assessment?

1)	Headache, muscle spasm, and weight gain
2)	Muscle weakness, lethargy, and irregular heartbeat
3)	Postural hypotension, thirst, and increased blood pressure
4)	Twitching, cramping pain, and diarrhea

____ 23. A patient’s laboratory test results indicate a negative finding on an infectious mononucleosis screen. The health-care provider, however, is concerned that this result could be a false-negative due to an interfering factor. Which of the following could cause such a false-negative finding?

1)	Cocaine addition
2)	Lymphoma
3)	Hepatitis
4)	Test conducted fewer than 6 days after exposure to the virus

____ 24. A high school student is undergoing a required annual sports physical screening examination. A nurse notes that the student’s serum creatinine level is 1.3 mg/dL. Which additional laboratory data should the nurse consider in order to assess the significance of this result?

1)	Albumin level
2)	Blood urea nitrogen
3)	Hemoglobin level
4)	Triglyceride level

____ 25. A patient has an order for a blood test for antisperm antibodies. Which condition should a nurse plan to manage if this test is positive?

1)	Infertility
2)	Prostate cancer
3)	Prostatic hypertrophy
4)	Testicular cancer

____ 26. A patient diagnosed with chronic obstructive pulmonary disease (COPD) has a carboxyhemoglobin level of 5%. When planning care for this patient, which question should a nurse ask to determine the significance of this result?

1)	“Do you experience a headaches or dizziness?”
2)	“How many cigarettes do you smoke each day?
3)	“How often do you exercise outdoors?”
4)	“What kind of heating do you have in your home?”

____ 27. A patient with a history of sickle cell disease has a total bilirubin level of 0.9 mg/dL with a direct bilirubin level of 0.3 mg/dL. Which additional data should the nurse obtain to plan care for this patient?

1)	None, these results are normal.
2)	Ultrasound of the gallbladder
3)	Liver function tests
4)	Serum electrolytes

____ 28. A nurse assessing a patient with a history of inflammatory bowel disease notes bilateral pitting edema of both the ankles and feet. Which laboratory result is most likely related to this finding?

1)	Decreased albumin
2)	Elevated triglycerides
3)	Elevated cholesterol
4)	Elevated platelet count

____ 29. A patient diagnosed with coronary artery disease begins therapy with simvastatin (Zocor). Which laboratory result should the nurse monitor to determine the effectiveness of this treatment?

1)	Aspartate aminotransferase (AST)
2)	Alkaline phosphatase (ALP)
3)	Alanine aminotransferase (ALT)
4)	Total cholesterol

____ 30. A patient with a serum phosphate level of 1.1 mg/dL is receiving IV sodium phosphate. When administering sodium phosphate, a nurse should monitor closely for:

1)	Laryngeal stridor, dysphagia, and circumoral numbness
2)	Lethargy, decreased deep tendon reflexes, and somnolence
3)	Nausea, vomiting, and diarrhea
4)	Weakness, confusion, and constipation

____ 31. When reviewing the laboratory results for an adult patient with elevated parathyroid hormone (PTH), which other laboratory result should the nurse interpret as significant?

1)	Alanine aminotransferase (ALT) 850 units/L
2)	Alkaline phosphatase (ALP) 250 units/L
3)	Aspartate aminotransferase (AST) 650 units/L
4)	Creatine phosphokinase (CK) 360 units/L

____ 32. A patient who is receiving chemotherapy has a white blood cell count of 7,200 cells/mm³ and a platelet count of 66.2 ´ 10³/mm³. Which order should the nurse question for this patient?

1)	Acetaminophen 650 mg by mouth every 4 hours as needed for pain
2)	Docusate (Colace) 1 to 2 tablets as needed
3)	Eszopiclone (Lunesta) 2 mg by mouth at bedtime as needed
4)	Pneumococcal vaccine polyvalent (Pneumovax) 0.5 mL intramuscularly

____ 33. A patient is suspected of having Wegener’s syndrome. Which of the following antibody tests should the nurse expect to conduct on this patient to confirm this suspicion?

1)	Anti-cyclic citrullinated peptide (Anti-CCP)
2)	Anti-glomerular basement membrane (anti-GBM)
3)	Actin (smooth muscle) and mitochondrial M2
4)	Antineutrophilic cytoplasmic

____ 34. A patient is suspected of having biliary cirrhosis. Which of the following antibody tests should the nurse expect to conduct on this patient to confirm this suspicion?

1)	Anti-cyclic citrullinated peptide (anti-CCP)
2)	Anti-glomerular basement membrane (anti-GBM)
3)	Actin (smooth muscle) and mitochondrial M2
4)	Antineutrophilic cytoplasmic

____ 35. The results of a patient’s adrenocorticotropic hormone (ACTH) test show a decreased cortisol level and an increased ACTH level. Which of the following conditions do these results most likely indicate?

1)	Addison’s disease
2)	Cushing’s disease

Test 1

Answer Section

MULTIPLE CHOICE

1. ANS: 3

Feedback: The nurse’s priority should be planning interventions to prevent opportunistic infections for the patient with CML and significant leukocytosis.

Page: 529

Monograph: Complete Blood Count, WBC Count and Differential

Content Area: Potential for Alterations in Body Systems

Integrated Processes: Nursing Process – Implementation

Client Need: Reduction of Risk Potential

Cognitive Level: Analysis

Concept: Infection

PTS: 1 CON: Infection

2. ANS: 1

Feedback: The glycated hemoglobin test (hemoglobin A_1c) is used to monitor treatment in individuals with diabetes by evaluating their long-term glycemic control. Glucose level is used to assist in the diagnosis of diabetes and to evaluate disorders of carbohydrate metabolism such as malabsorption syndrome. G6PD level is used to identify an enzyme deficiency that can result in hemolytic anemia. Glucose tolerance tests are used to evaluate blood glucose levels to assist in diagnosing diseases such as diabetes.

Heading: Glycated Hemoglobin

Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Reduction of Risk Potential

Cognitive Level: Application [Applying]

Concept: Metabolism

Page: 874

Difficulty: Moderate

PTS: 1 CON: Metabolism

3. ANS: 1

Feedback: The nurse recognizes that the high urine pH is most likely related to the history of maintaining a vegetarian diet since a diet high in citrus fruits, vegetables, and dairy products can increase urine pH.

Page: 1562

Monograph: Urinalysis

Content Area: Laboratory Values

Integrated Processes: Nursing Process – Analysis

Client Need: Reduction of Risk Potential

Cognitive Level: Analysis

Concept: Nutrition

PTS: 1 CON: Nutrition

4. ANS: 4

Feedback: The nurse should instruct the patient to withhold vitamin B₁₂ for 48 hours before the test is scheduled since injected or ingested B₁₂ can invalidate the results.

Page: 994

Monograph: Intrinsic Factor Antibodies

Content Area: Diagnostic Tests

Integrated Processes: Nursing Process – Implementation

Client Need: Reduction of Risk Potential

Cognitive Level: Analysis

Concept: Hematologic Regulation

PTS: 1 CON: Hematologic Regulation

5. ANS: 2

Feedback: The nurse should plan interventions to manage DKA. DKA is characterized by a fruity odor of the breath and urine and an altered level of consciousness.

Page: 1005

Monograph: Ketones, Blood and Urine

Content Area: Alterations in Body Systems

Integrated Processes: Nursing Process – Planning

Client Need: Physiological Adaptation

Cognitive Level: Application

Concept: Metabolism

PTS: 1 CON: Metabolism

6. ANS: 3

Feedback: A nonionic contrast medium should be used for the procedure if the patient has a history of allergic reactions to any substance or drug. Removal of all metallic objects is a standard intervention before any x-ray imaging. The nurse should administer an antianxiety agent, as ordered, if the patient has claustrophobia. There is no need to cancel the procedure, because a nonionic contrast medium can be used.

Heading: Angiography, Pulmonary

Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Reduction of Risk Potential

Cognitive Level: Application [Applying]

Concept: Immunity

Page: 102

Difficulty: Moderate

PTS: 1 CON: Immunity

7. ANS: 3

Feedback: Elevated AFP levels and presence of AChE indicate a neural tube defect. A lecithin/sphingomyelin ratio of less than 2:1 and absence of phosphatidylglycerol at term indicate fetal lung immaturity and possible respiratory distress syndrome. Elevated bilirubin levels indicate fetal hemolytic disease or intestinal obstruction. Creatinine concentration greater than 2 mg/dL indicates fetal maturity (at 36 to 37 weeks) if maternal creatinine is also within the expected range.

Heading: Amniotic Fluid Analysis and L/S Ratio

Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Reduction of Risk Potential

Cognitive Level: Application [Applying]

Concept: Pregnancy

Page: 57

Difficulty: Difficult

PTS: 1 CON: Pregnancy

8. ANS: 4

Feedback: A low C-peptide indicates type 1 diabetes with an elevated blood glucose, so the nurse should instruct the patient that insulin will be required.

Page: 618

Monograph: C-Peptide

Content Area: Illness Management

Integrated Processes: Teaching and Learning

Client Need: Physiological Adaptation

Cognitive Level: Analysis

Concept: Metabolism

PTS: 1 CON: Metabolism

9. ANS: 4

Feedback: If the patient is responding to the administration of iron for iron-deficiency anemia, the nurse would expect to see increased reticulocytes, immature red blood cells produced by the bone marrow.

Page: 1363

Monograph: Reticulocyte Count

Content Area: Laboratory Values

Integrated Processes: Nursing Process – Evaluation

Client Need: Reduction of Risk Potential

Cognitive Level: Application

Concept: Hematologic Regulation

PTS: 1 CON: Hematologic Regulation

10. ANS: 3

Feedback: The accuracy of the creatinine clearance test requires careful collection of urine over a defined 24-hour period, so the nurse must empty all urine in the urinary drainage bag or, if the patient is not catheterized, ask the patient to void and discard the first specimen, at 0600. Then save all urine until the next day at 0600.

Page: 642

Monograph: Creatinine, Urine, and Creatinine Clearance, Urine

Content Area: Diagnostic Tests

Integrated Processes: Nursing Process – Implementation

Client Need: Reduction of Risk Potential

Cognitive Level: Application

Concept: Urinary Elimination

PTS: 1 CON: Urinary Elimination

11. ANS: 1

Feedback: To perform a lumbar puncture, position the patient in the knee-chest position at the side of the bed. Provide pillows to support the spine or for the patient to grasp. The sitting position is an alternative. In this position, the patient must bend the neck and chest to the knees. The sidelying, prone, and standing positions are not appropriate for this test.

Heading: Alzheimer’s Disease Markers

Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Reduction of Risk Potential

Cognitive Level: Application [Applying]

Concept: Cognition

Page: 45

Difficulty: Moderate

PTS: 1 CON: Cognition

12. ANS: 4

Feedback: The PT and international normalized ratio (INR) should both be monitored to determine the therapeutic range for a patient receiving warfarin.

Page: 1319

Monograph: Prothrombin Time and International Normalized Ratio

Content Area: Laboratory Values

Integrated Processes: Nursing Process – Evaluation

Client Need: Reduction of Risk Potential

Cognitive Level: Application

Concept: Clotting

PTS: 1 CON: Clotting

13. ANS: 3

Feedback: Moderate loss is 41 to 55 dB. Normal range is –10 to 15 dB. Slight loss is 16 to 25 dB. Profound loss is greater than 91 dB.

Heading: Audiometry, Hearing Loss

Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Reduction of Risk Potential

Cognitive Level: Application [Applying]

Concept: Sensory Perception

Page: 187

Difficulty: Moderate

PTS: 1 CON: Sensory Perception

14. ANS: 1

Feedback: After the IV radionuclide is administered, the patient is instructed to return for scanning at a designated time after injection. Typical scanning occurs at 6, 24, 48, 72, 96, and/or 120 hours postinjection, depending on diagnosis.

Heading: Gallium Scan

Integrated Processes: Nursing Process

Client Need: Safe and Effective Care Environment: Management of Care

Cognitive Level: Application [Applying]

Concept: Cellular Regulation

Page: 828

Difficulty: Moderate

PTS: 1 CON: Cellular Regulation

15. ANS: 2

Feedback: The nurse should assess the patient with an increased AChR level for clinical manifestations of myasthenia gravis since the muscle weakness associated with this disease is related to destruction of acetylcholine receptor sites.

Page: 2

Monograph: Acetylcholine Receptor Antibody

Content Area: Pathophysiology

Integrated Processes: Nursing Process – Assessment

Client Need: Physiological Adaptation

Cognitive Level: Analysis

Concept: Mobility

PTS: 1 CON: Mobility

16. ANS: 3

Feedback: Carotid angiography is used to visualize and assess the carotid arteries and surrounding tissues for abscess, tumors, and aneurysm and to evaluate for atherosclerotic disease related to stroke risk. Abdominal angiography is used to visualize and assess abdominal organs/structure for tumor, infection, or aneurysm. Adrenal angiography is used to visualize and assess the adrenal gland for cancer or other tumors or masses, such as pheochromocytoma. Coronary angiography is used to visualize and assess the heart and surrounding structures for abnormalities, defects, aneurysm, tumors, and to diagnose coronary artery disease.

Heading: Angiography, Carotid

Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Reduction of Risk Potential

Cognitive Level: Application [Applying]

Concept: Perfusion

Page: 85

Difficulty: Moderate

PTS: 1 CON: Perfusion

17. ANS: 1

Feedback: Sedentary lifestyle is associated with a decreased CK level.

Page: 627

Monograph: Creatine Kinase and Isoenzymes

Content Area: Laboratory Values

Integrated Processes: Nursing Process – Assessment

Client Need: Reduction of Risk Potential

Cognitive Level: Knowledge

Concept: Perfusion

PTS: 1 CON: Perfusion

18. ANS: 1

Feedback: The nurse should mix the radionuclide with orange juice and have the patient drink it.

Heading: Gastroesophageal Reflux Scan

Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Cognitive Level: Application [Applying]

Concept: Digestion

Page: 842

Difficulty: Moderate

PTS: 1 CON: Digestion

19. ANS: 1

Feedback: IFE is used to identify the individual types of immunoglobulins, toward diagnosing diseases such as multiple myeloma, and to evaluate effectiveness of chemotherapy. IgE testing is used to assess IgE levels to identify the presence of an allergic or inflammatory immune response, such as in hay fever. IgA testing is used to evaluate patients suspected of IgA deficiency prior to transfusion and to evaluate anaphylaxis associated with the transfusion of blood and blood products (anti-IgA antibodies may develop in patients with low levels of IgA, possibly resulting in anaphylaxis when donated blood is transfused). Testing of the immunosuppressant cyclosporine is done to assist in the management of treatments to prevent organ rejection and to monitor for toxicity.

Heading: Immunofixation Electrophoresis, Blood and Urine

Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Reduction of Risk Potential

Cognitive Level: Application [Applying]

Concept: Cellular Regulation

Page: 954

Difficulty: Moderate

PTS: 1 CON: Cellular Regulation

20. ANS: 1

Feedback: The nurse should interpret these results as an indication that the patient may have early signs of renal insufficiency.

Page: 633

Monograph: Creatinine, Blood

Content Area: System Specific Assessments

Integrated Processes: Nursing Process – Analysis

Client Need: Reduction of Risk Potential

Cognitive Level: Analysis

Concept: Urinary Elimination

PTS: 1 CON: Urinary Elimination

21. ANS: 2

Feedback: The initial test establishes the patient’s current HIV status. If this is negative, the most appropriate action is for the nurse to instruct the patient to schedule a follow-up test in 6 months since it takes that long for the body to develop antibodies that can be detected.

Page: 941

Monograph: Human Immunodeficiency Virus Type 1 and Type 2 Antibodies

Content Area: Potential for Alterations in Body Systems

Integrated Processes: Nursing Process – Implementation

Client Need: Reduction of Risk Potential

Cognitive Level: Analysis

Concept: Infection

PTS: 1 CON: Infection

22. ANS: 2

Feedback: The nurse should assess the patient for signs of hypokalemia, such as muscle weakness, lethargy, or irregular heartbeat. While hypokalemia may be asymptomatic, it is especially important to monitor the patient’s cardiac status.

Page: 1282

Monograph: Potassium, Blood

Content Area: Alterations in Body Systems

Integrated Processes: Nursing Process – Assessment

Client Need: Physiological Adaptation

Cognitive Level: Analysis

Concept: Fluid and Electrolyte Balance

PTS: 1 CON: Fluid and Electrolyte Balance

23. ANS: 4

Feedback: A false-negative result may occur if treatment was begun before antibodies developed or if the test was done less than 6 days after exposure to the virus. False-positive results may occur in the presence of narcotic addiction, serum sickness, lymphomas, hepatitis, leukemia, cancer of the pancreas, and phenytoin therapy.

Heading: Infectious Mononucleosis Screen

Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Reduction of Risk Potential

Cognitive Level: Application [Applying]

Concept: Infection

Page: 974

Difficulty: Moderate

PTS: 1 CON: Infection

24. ANS: 2

Feedback: The ratio of serum creatinine to blood urea nitrogen is important when interpreting the significance of either result.

Page: 632

Monograph: Creatinine, Blood

Content Area: Laboratory Values

Integrated Processes: Nursing Process – Assessment

Client Need: Reduction of Risk Potential

Cognitive Level: Analysis

Concept: Urinary Elimination

PTS: 1 CON: Urinary Elimination

25. ANS: 1

Feedback: The nurse should plan to provide infertility counseling, since the test is used to identify the presence of antibodies that lower the sperm count over time.

Page: 128

Monograph: Antibodies, Antisperm

Content Area: Potential for Alterations in Body Systems

Integrated Processes: Nursing Process – Planning

Client Need: Reduction of Risk Potential

Cognitive Level: Analysis

Concept: Male Reproduction

PTS: 1 CON: Male Reproduction

26. ANS: 2

Feedback: The nurse should ask about smoking habits since smokers can have carboxyhemoglobin levels up to 12%. If the patient is not smoking, the nurse should ask additional questions to determine possible exposure to carbon monoxide.

Page: 370

Monograph: Carboxyhemoglobin

Content Area: System Specific Assessments

Integrated Processes: Nursing Process – Assessment

Client Need: Reduction of Risk Potential

Cognitive Level: Analysis

Concept: Oxygenation

PTS: 1 CON: Oxygenation

27. ANS: 1

Feedback: Destruction of red blood cells during a sickle cell crisis could increase bilirubin, but these results are within normal limits, so no additional information is needed.

Page: 207

Monograph: Bilirubin and Bilirubin Fractions

Content Area: Laboratory Values

Integrated Processes: Nursing Process – Planning

Client Need: Reduction of Risk Potential

Cognitive Level: Analysis

Concept: Hematologic Regulation

PTS: 1 CON: Hematologic Regulation

28. ANS: 1

Feedback: Since proteins in the blood maintain the osmotic pressure gradient that keeps water in the vascular spaces, the nurse should observe for decreased albumin that will contribute to the movement of water from the vascular to the interstitial spaces.

Page: 25

Monograph: Albumin and Albumin/Globulin Ratio

Content Area: Laboratory Values

Integrated Processes: Nursing Process – Assessment

Client Need: Reduction of Risk Potential

Cognitive Level: Analysis

Concept: Fluid and Electrolyte Balance

PTS: 1 CON: Fluid and Electrolyte Balance

29. ANS: 4

Feedback: Statins such as simvastatin (Zocor) inhibit a liver enzyme, HMG Co-A reductase, reducing the liver’s ability to make cholesterol. This results in a significant decrease in low-density lipoprotein (LDL) “bad” cholesterol levels, so the nurse should monitor total cholesterol to determine the patient’s response to treatment.

Page: 430

Monograph: Cholesterol, Total

Content Area: Laboratory Values

Integrated Processes: Nursing Process – Evaluation

Client Need: Reduction of Risk Potential

Cognitive Level: Application

Concept: Perfusion

PTS: 1 CON: Perfusion

30. ANS: 1

Feedback: The nurse should monitor for signs of hypocalcemia, such as laryngeal stridor, dysphagia, and circumoral numbness, since rapid infusion of phosphate may shift calcium levels.

Page: 345

Monograph: Calcium, Blood

Content Area: Pharmacological Agents/Actions

Integrated Processes: Nursing Process – Evaluation

Client Need: Pharmacological and Parenteral Therapies

Cognitive Level: Analysis

Concept: Fluid and Electrolyte Balance

PTS: 1 CON: Fluid and Electrolyte Balance

31. ANS: 2

Feedback: The nurse should interpret elevated ALP as significant for bone loss in patients with increased PTH.

Page: 35

Monograph: Alkaline Phosphatase and Isoenzymes

Content Area: Alterations in Body Systems

Integrated Processes: Nursing Process – Analysis

Client Need: Physiological Adaptation

Cognitive Level: Analysis

Concept: Mobility

PTS: 1 CON: Mobility

32. ANS: 4

Feedback: The nurse should question any order for an intramuscular injection due to the increased risk for bleeding. If this vaccination cannot be delayed until the platelet count improves, a subcutaneous injection may be preferred.

Page: 499

Monograph: Complete Blood Count, Platelet Count

Content Area: Expected Actions/Outcomes

Integrated Processes: Nursing Process – Analysis

Client Need: Pharmacological and Parenteral Therapies

Cognitive Level: Analysis

Concept: Hematologic Regulation

PTS: 1 CON: Hematologic Regulation

33. ANS: 4

Feedback: Antineutrophilic cytoplasmic antibodies test is performed to assist in diagnosing and monitoring the effectiveness of therapeutic interventions for Wegener’s syndrome. The anti-CCP antibodies test is performed to assist in diagnosing and monitoring rheumatoid arthritis. The anti-GBM antibodies test is performed to assist in differentiating Goodpasture’s syndrome (an autoimmune disease) from renal dysfunction. The actin (smooth muscle) and mitochondrial M2 antibodies test is performed to assist in the differential diagnosis of chronic liver disease, typically biliary cirrhosis.

Heading: Antibodies, Antineutrophilic Cytoplasmic

Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Reduction of Risk Potential

Cognitive Level: Application [Applying]

Concept: Immunity

Page: 128

Difficulty: Moderate

PTS: 1 CON: Immunity

34. ANS: 3

Feedback: The actin (smooth muscle) and mitochondrial M2 antibodies test is performed to assist in the differential diagnosis of chronic liver disease, typically biliary cirrhosis. The anti-CCP antibodies test is performed to assist in diagnosing and monitoring rheumatoid arthritis. The anti-GBM antibodies test is performed to assist in differentiating Goodpasture’s syndrome (an autoimmune disease) from renal dysfunction. Antineutrophilic cytoplasmic antibodies test is performed to assist in diagnosing and monitoring the effectiveness of therapeutic interventions for Wegener’s syndrome.

Heading: Antibodies, Actin (Smooth Muscle) and Mitochondrial M2

Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Reduction of Risk Potential

Cognitive Level: Application [Applying]

Concept: Immunity

Page: 127

Difficulty: Moderate

PTS: 1 CON: Immunity

35. ANS: 1

Feedback: A decreased cortisol level and an increased ACTH level indicate Addison’s disease. Increased levels of both cortisol and ACTH indicate either Cushing’s disease (pituitary adenoma) or Cushing’s syndrome related to ectopic source of ACTH. An increased cortisol level and decreased ACTH level indicate Cushing’s syndrome (ACTH-independent).

Heading: Adrenocorticotropic Hormone (and Challenge Tests)

Integrated Processes: Nursing Process

Client Need: Physiological Integrity: Reduction of Risk Potential

Cognitive Level: Analysis [Analyzing]

Concept: Metabolism

Page: 16

Difficulty: Difficult