17 minute read
Chapter 10: Diagnostic Procedures
from TEST BANK FOR NURSING INTERVENTIONS & CLINICAL SKILLS, 7TH EDITION BY PERRY, POTTER. Test Bank with
by ACADEMIAMILL
Multiple Choice
1. The patient asks the nurse why an x-ray film with contrast medium is needed. How would the nurse respond?
a. “Most patients ask me that question.” b. “It enhances visualization of the internal structures.” c. “It guarantees accuracy of the x-ray film interpretation.” d. “Let me have you speak to the radiologist.”
ANS: B
The radiologist uses contrast medium to visualize internal structures not seen with regular x-ray films. The dye saturates the affected area for the x-ray film, and the image stands out against the tissue without dye. Because the health care provider and radiologist know the normal contour and appearance of internal structures, they can spot abnormalities such as filling defects, tumors, fistulas, and fractures. The nurse needs to be direct and answer the patient’s question. Nothing guarantees accuracy.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. “I’m allergic to shellfish.” b. “I have small veins in my left arm.” c. “I’m really worried about the test results.” d. “I’m really terrified about this procedure.”
2. A contrast medium study is being scheduled. Which statement by the patient during the assessment warrants further investigation by the nurse?
ANS: A
The nurse needs to establish whether the patient is truly allergic to shellfish, indicating sensitivity to iodine. The antiseptic used for the test has an iodine base and might cause a reaction; if so, the nurse or provider uses chlorhexidine or another agent for the skin preparation before the study. In addition, because many contrast mediums have an iodine base, the provider needs to choose an alternative dye. Establishing the nature of the reaction is important because the information provides valuable data for the radiologist to aid in choosing the proper contrast medium. It also establishes baseline data necessary when preparing for postprocedure nursing care. The nurse does need to investigate the statements of being worried or terrified, but those are not the priority. Small veins will not be used for this procedure.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. The patient can’t remember the procedure. b. The left pedal and posterior tibial pulses are palpable. c. The patient hasn’t voided yet. d. Both of the patient’s feet are cool and pink.
3. A patient is being monitored 2 hours after an angiogram using the femoral artery. What assessment by the nurse best indicates outcomes are being met?
ANS: B
Because the provider punctured a large artery during the procedure, the nurse assesses that blood flow distal to the insertion site is not compromised. Palpable pulses indicate the blood flow is intact. With sedation agents, it is common to not remember procedures. Not voiding within 2 hours is not a problem. If both patient’s feet are cool and pink, this is probably due to environmental factors. If only one foot was cool, the nurse would investigate further.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. The patient has been placed in the left lateral position. b. An anterior gastric erosion ulcer is present. c. The blood pressure has dropped 30 mm Hg. d. The patient is lethargic but can follow directions.
4. The nurse is monitoring a patient during a gastroscopy. Which patient data need to be communicated to the health care provider doing the procedure?
ANS: C
Inserting the endoscope can stimulate the vagus nerve, potentially leading to a slower heart rate and hypotension. Left lateral Sims’ position is suitable for gastroscopy. The patient should be drowsy with the medication used but able to follow basic directions. The nurse and health care provider use the gastric erosion identified during the gastroscopy to plan nursing care and patient therapy.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation a. “You can move freely during this procedure.” b. “I’ll place you in a semi-Fowler’s position.” c. “It is essential to remain still during the procedure.” d. “We’ll restrict your fluids after the test is done.”
5. The nurse provides patient teaching before a lumbar puncture. Which information does the nurse include about patient activity during the procedure?
ANS: C
The nurse instructs the patient to maintain the lateral position and lie without moving during the procedure, especially while the provider inserts the needle, because the goal is to put the needle in the subarachnoid space. Unexpected patient movement potentially leads to needle misplacement, patient injury, and increased risk of postprocedural headache and infection from leaking cerebrospinal fluid. The local anesthetic injection stings, and insertion of the needle potentially elicits a sharp, stabbing, or shooting pain that causes patients to flinch. The nurse assists the patient to maintain the position and offers reassurance and information. The nurse instructs the patient to indicate verbally that pain is present during the procedure but not to move. Unless fluids are contraindicated, providers typically prescribe flat positioning and normal fluid intake following the procedure.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Integrated Process: Teaching-Learning a. It will relieve pressure and some of the discomfort in your abdomen. b. It will allow for analysis of the thoracic fluid for cytology. c. Fluid from the lung will be examined. d. The examination will extract a sample of bone marrow.
6. A patient has had increasing respiratory difficulty as a result of abdominal cancer. Which information does the nurse provide to the patient about the purpose of having a paracentesis?
ANS: A
Paracentesis is the removal of abdominal fluid for examination and relief of pressure from severe ascites. The removal of the fluid can increase patient comfort and ease breathing. A thoracentesis removes fluid from the chest cavity. Lung fluid is not obtained during a paracentesis. A bone marrow aspiration recovers bone marrow cells.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Have the patient hold the breath for a few seconds. b. Ensure that the patient voids before the procedure. c. Place the patient in a supine position. d. Check vital signs every 2 hours after the procedure.
7. The nurse is explaining the procedure for a paracentesis. Which intervention by the nurse can help prevent a complication of the procedure?
ANS: B
The nurse instructs the patient to void before the paracentesis because an empty bladder reduces the risk of an accidental bladder puncture. The patient doesn’t need to hold his or her breath. The nurse helps the patient into a sitting position because sitting decreases the size of the peritoneal cavity. Vital signs are measured every 15 minutes for 2 hours.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Ambulate the patient to see if the pain diminishes. b. Monitor the vital signs every 5 minutes. c. Encourage oral intake of fluids as desired by the patient. d. Sit the patient in a high-Fowler’s position.
8. A patient develops low back pain radiating to both sides of the body after a femoral approach has been used for a cardiac catheterization. What should the nurse do while contacting the health care provider?
ANS: B
The patient may be experiencing a complication such as retroperitoneal bleeding, which is an emergency. Surgery or further intervention will most likely be required; therefore the patient needs to be NPO and kept in a position that supports the blood pressure best, which is supine. The patient’s status must be monitored frequently because of the severity of the situation.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation a. Checking the left femoral region for bleeding b. Monitoring patient vital signs every 15 minutes c. Applying direct pressure at the patient’s IV site d. Palpating the right pedal pulse for pulsations
9. The patient arrives in the post anesthesia care unit after a cardiac catheterization via the left femoral artery to assess the right atrium. Which patient datum is the nurse’s priority to assess perfusion of the affected extremity after the procedure?
ANS: A
To access the right heart, the provider used a femoral approach, which is the site where bleeding would occur after the procedure. The nurse measures vital signs every 15 minutes after a cardiac catheterization; however, unless the femoral vein is bleeding, the vital signs provide secondary evidence about the perfusion to the affected extremity. The nurse palpates the unaffected extremity as a comparison for the affected extremity. Applying pressure is a nursing intervention and will not provide patient data regarding perfusion.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment a. The chemicals in the dye injection help prevent hemorrhage. b. The patient will be sleepy; so movement will be minimal. c. The patient’s affected leg will be immobilized after the procedure. d. Postprocedure analgesia will manage patient discomfort.
10. The nurse prepares a patient for a pulmonary angiogram. What information should the nurse include in patient teaching to prevent a postprocedure hemorrhage?
ANS: C
The nurse explains that the patient’s hips and knees will be kept straight and positioned for little movement for 2–6 hours after the procedure. The nurse also explains that flat straight extremities allow adequate hemostasis to prevent postprocedure bleeding by protecting the integrity of the insertion site. Sleepiness is expected after the procedure and is not involved in prevention of a postprocedure hemorrhage. The contrast dye and postprocedure analgesia will not interfere with the ability of the blood to clot.
N
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Limit the patient’s total fluid intake. b. Encourage early patient ambulation. c. Elevate the head of the bed 30 degrees. d. Apply constant pressure to the insertion site.
11. The nurse is caring for the patient immediately after an angiogram has been finished. Which action does the nurse take to prevent a complication of this procedure?
ANS: D
Significant pressure applied to the insertion site of the angiographic catheter helps to ensure hemostasis and prevent a post-angiograph hemorrhage. The pressure is kept in place for up to 6 hours if no closure device was used. Fluid intake increases after an angiogram to flush the dye from the system quickly to prevent renal damage. Following the angiogram, the patient is kept supine.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Pallor b. Pruritus c. Tachycardia d. Cool skin
12. The nurse cares for a patient who had an angiogram of the aorta with a contrast medium approximately 4 hours ago. Which is the priority patient assessment for the nurse to monitor for detection of an allergic reaction to the dye?
ANS: C
The nurse monitors the patient’s respiratory and cardiac status for any indication of a hypersensitivity reaction to the dye. Tachycardia can be a delayed sign of an allergic reaction. Other clinical indicators include flushing, itching, and urticaria. Pallor is usually an indicator of altered cardiovascular status. Pruritus and cool skin may be an indication of allergic reactions; however, they are not as high on the patient’s hierarchy of needs as the heart rate.
DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment a. “Do you ever feel claustrophobic?” b. “Are you allergic to iodine or shellfish?” c. “Have you ever had an electrocardiogram?” d. “Can you lie on your stomach for 20–30 minutes?”
13. A patient is admitted for possible leukemia. Prior to assisting with the definitive diagnostic procedure, which question does the nurse ask?
ANS: D
To rule out leukemia, the patient needs to have a bone marrow biopsy to examine the marrow for malignant white blood cells. A bone marrow biopsy requires the patient to lie in the lateral or prone position when the provider chooses to obtain the bone marrow specimen from the iliac crest. These positions provide access to the hip and allow the provider to apply enough pressure to reach the marrow with the hollow core needle. If the patient cannot tolerate the positioning, the provider can choose the sternum. Allergies to shellfish and iodine are of key interest when performing tests that use contrast medium. Claustrophobia is important to determine before computed tomography or magnetic resonance imaging. The nurse asks about previous electrocardiograms to compare with current electrocardiograms.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Deep breathe during the insertion of the bronchoscope for easy passage of the scope. b. Do not eat or drink anything after the procedure until the nurse says it is safe to drink. c. Turn on your right side while the bronchoscope is passed through the nose and throat. d. Avoid food and fluids for at least 8 hours before the procedure.
14. The nurse is teaching an older patient before a bronchoscopy. What information is the most important for the patient to know to prevent a possible postprocedure complication?
ANS: B
The nurse cautions the patient to avoid taking anything by mouth after the bronchoscopy unt il approved by the nurse because the nurse determines when the gag reflex returns. The health care provider sprays a local anesthetic agent to depress the gag reflex before passing the bronchoscope. Ingesting oral food or fluid potentially causes choking or aspiration with a depressed gag reflex. The patient is NPO for 2–6 hours before the bronchoscopy to help prevent aspiration of gastric contents. IV sedation is often used to relax the patient, allowing for easy passage of the bronchoscope. The bronchoscope passes through the oropharynx into the trachea, not through the nose.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Status of the gag reflex b. Level of sedation c. Circulatory status d. Respiratory status
15. The patient arrives in the intensive care unit after a bronchoscopy. Which patient assessment is the nurse’s priority?
ANS: D
Respiratory status is the priority assessment in the immediate postprocedure period because bronchoscopy includes manipulation of a scope through the trachea and bronchi, potentially stimulating bronchospasm, laryngospasm, and respiratory distress. Cardiovascular status, or circulation, is the next patient priority on the hierarchy of needs. After the respiratory and cardiovascular assessments, the nurse assesses the patient’s neurological status and sedation level to monitor for return of function. The nurse assesses the gag reflex before administering anything by mouth.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment a. Remove the patient’s dentures. b. Suction the oral cavity. c. Provide a sip of clear fluid. d. Position the patient upright in bed.
16. The nurse is preparing to position a patient for a gastroscopy. Which action should the nurse implement before getting the patient into position?
ANS: A
The nurse assists the patient in removing dentures before the procedure to protect the dentures, prevent accidental dislodgement, and facilitate patient comfort. Suctioning is not indicated before positioning. The nurse positions the patient in the left lateral Sims’ position during the procedure and in the semi-Fowler’s or the recovery position after the procedure. The patient should be NPO prior to the procedure.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Hydration status b. Level of orientation c. Skin integrity status d. A reaction to contrast medium used
17. An older patient has been NPO for 8 hours before a bronchoscopy. When the patient returns from the test, which is the nurse’s priority assessment?
ANS: A
Older patients are especially prone to dehydration, and the risk increases after a prolonged NPO period because the nurse withholds food and fluid to prepare the patient for the procedure. The patient’s urinary output needs to be watched after hydration has been established. Emptying the stomach decreases the risk of aspiration of gastric contents during and after the procedure. Disorientation is a reasonable assessment for an older adult who has received inadequate fluid and risks dehydration; it may be a clinical indicator of dehydration. The risk of skin breakdown is increased with dehydration. It is not as important as early detection of dehydration because preventing dehydration helps to prevent skin breakdown. A contrast medium is not used during a bronchoscopy. The procedure is a direct visualization.
DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment a. Ask the patient how he or she is feeling since the dye was injected. b. Tell the patient that many patients feel the same way. c. Assess the patient’s vital signs while reassuring him or her. d. Explain to the patient that this is a normal sensation for this test.
18. A patient is having a contrast medium study and has several allergies. During the injection of the dye, the patient complains of having a brief, severe hot flash and slight chest pain. What nursing action is most indicated?
ANS: C
Obtaining objective data is the best indicator of the patient’s status. Asking the patient how he feels may be helpful, but it results in only subjective data. Telling the patient that others feel the same way is nontherapeutic. The patient concern should be answered honestly and completely. Many of the contrasts such as those for angiography can cause a sensation of warmth shortly after the injection, but specific evaluation of the patient’s status is required.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Maintain airway. b. Reduce total fluid intake. c. Lie the patient flat. d. Maintain pressure on the LP site.
19. The nurse is caring for a patient who had a lumbar puncture (LP) 1 hour ago. The patient is drowsy and the pupils are dilated. After notifying the health care provider, what should the nurse do?
ANS: A
A patient undergoing an LP can develop an excessive loss of CSF, which causes reduced LOC, dilated pupils, and increased BP. The nurse should first maintain the airway. The nurse would then notify the health care provider, monitor vital signs, and prepare to transfer the patient to the ICU. The patient should not be flat because that would compromise the airway. Pressure on the site will not stop the leak, and the patient should have not fluids restricted.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Cough only when requested. b. Swallow and clear the throat. c. Remain sitting but motionless. d. Inhale during needle insertion.
20. The nurse is preparing a tired older patient for a thoracentesis. Which ability should the nurse assess for when determining if the patient can tolerate the procedure safely?
ANS: C
The nurse should assess the patient’s ability to remain motionless in a sitting position during the procedure so the provider can precisely place the needle in the fluid without puncturing adjacent structures inadvertently, including the heart and great vessels. The nurse instructs the patient to avoid coughing and throat clearing during a thoracentesis to prevent accidental injury. The nurse instructs the patient to hold his or her breath during a thoracentesis to prevent accidental injury to adjacent thoracic structures.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment a. “This will decrease the chance of an allergic response.” b. “Excessive hydration causes dilution of the contrast medium.” c. “It reduces the chance of postprocedure infection.” d. “Nausea is prevented if the stomach is empty.”
21. A patient asks the nurse why being NPO for 6–8 hours before a contrast study is necessary. Which response by the nurse is most accurate?
ANS: B
Excessive hydration causes dilution of the contrast medium, making structures more difficult to see. The hydration status has not affected the chance of an allergic response to the contrast medium. Postprocedure infection is rare with a contrast study and being NPO has nothing to do with its occurrence. Having an empty stomach does not prevent nausea. Nausea may result from the contrast medium used for the study.
DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning a. Document the findings. b. Prepare to increase the oxygen flow. c. Administer a drug-reversal agent. d. Listen to the breath sounds.
22. A patient is recovering after receiving sedation for a contrast medium study and has a score of 2 using the Modified Ramsay Sedation Scale. What action by the nurse is most appropriate at this time?
ANS: A
A score of 2 reflects a patient who is cooperative, oriented, and tranquil. Documentation is the only action needed. There is no need to increase the oxygen flow based on the patient’s optimum status. A drug-reversal agent is not needed based on current assessment data. There are no data that point to the need to assess breath sounds at the current time.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Raise the head of the bed and call the nursing supervisor. b. Give oxygen to the patient and notify the physician. c. Look at the chest excursion and notify respiratory therapy. d. Open a chest tube insertion kit and notify the patient’s family.
23. An hour after a patient has a thoracentesis, the patient’s oxygen saturation is 88%, and respiratory rate is 34 breaths per minute. What actions by the nurse are priorities?
ANS: B
The patient most likely has a punctured lung and needs respiratory support. He or she must not be left alone. Oxygen is needed, and the physician must be notified immediately. Raising the head of the bed does not increase the flow of oxygen. Further assessment is not a priority until the oxygen is on and either the physician or respiratory therapy is at the bedside. The nurse should not assume that a chest tube will be inserted. The tray must be kept closed until immediately before being used. The physician needs to be called before the family is called.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation a. Flumazenil b. Naloxone c. Diphenhydramine d. Epinephrine
24. The nurse is caring for a patient who received opioids for sedation during a procedure. After the procedure the patient experiences oversedation that required the administration of a reversal agent. Which agent would the nurse administer?
ANS: B
If a patient is oversedated, be prepared to administer emergency medications or reversal agents (e.g., naloxone [reversal of opioids] or flumazenil [reversal of benzodiazepines]). Other support drugs may also be given. Diphenhydramine would be given for an allergic reaction. Epinephrine does not reverse opioids.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
Multiple Response
1. A patient is going to have a cardiac procedure that requires moderate sedation. The nurse is explaining to the patient what is included in the pre-sedation assessment. Which questions by the nurse are most appropriate? (Select all that apply.)
a. “Have you arranged for someone to drive you home after the procedure?” b. “How frequently do you drink alcohol?” c. “Have you had any problems with anesthesia before?” d. “Do you have any drug allergies?” e. “Do you currently use any drugs? How frequently have you used drugs in the past?” f. “Is there a family history of drug use or abuse?”
ANS: A, B, C, D, E
One of the risks for moderate sedation is if it progresses past the point and becomes deep sedation. Because of this risk, only trained individuals can give the sedation and a pre-assessment is completed to help ensure patient risk factors are known. The patient’s level of tolerance for the sedatives used can be affected by his or her history of drug and alcohol use. The patient must also arrange for someone to take him or her home after the procedure. Current drug allergies will prevent an allergic reaction. Past family history does not impact the patient.
DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment a. The time-out is done at the start of every invasive procedure. b. The time-out prevents wrong site errors. c. The time-out prevents wrong patient errors. d. The time-out is done by the surgeon. e. The time-out is required by The Joint Commission (TJC).
2. The nurse is describing the “time-out” verification procedure to a nursing orientee. Which statements by the orientee indicate a good level of understanding? (Select all that apply.)
ANS: A, B, C, E
The time-out verification procedure is required by TJC and is done before every invasive procedure by the physician and all involved personnel. This is a safety procedure that prevents wrong patient, wrong site, and wrong procedure errors.
DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation a. Feeling faint b. Light-headed c. Flushing d. Dizzy e. Itching
3. The nurse is caring for a patient post cardiac catheterization who experiences a vasovagal response when the sheaths are removed and pressure is applied. Which of the following symptoms is the patient likely to experience? (Select all that apply.)
ANS: A, B, D
A patient experiences a vasovagal response (occurs at the time of femoral puncture or after the procedure when femoral pressure is applied). Symptoms include feeling faint, dizzy, light-headed, and possible loss of consciousness for a few seconds. Bradycardic pulse is caused by stimulation of the vagus nerve via baroreceptors. Itching and flushing occur with contrast dye.
DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
