Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a patient who has rheumatoid arthritis. Which of the following laboratory tests are used to diagnose the disease? (Select all that apply)
A. Antinuclear antibody (ANA) titer
Antinuclear antibody (ANA) titer is a blood test that detects the presence of antinuclear antibodies, which are autoantibodies that target the body's own tissues. These antibodies are often present in people with autoimmune diseases, including rheumatoid arthritis. While a positive ANA test does not definitively diagnose rheumatoid arthritis, it can support a diagnosis when considered alongside other clinical findings and laboratory tests.
B. BUN
Blood urea nitrogen (BUN) is a blood test that measures the amount of urea nitrogen in the blood. Urea nitrogen is a waste product that is produced when the body breaks down proteins. BUN levels can be elevated in people with kidney disease, dehydration, or certain other medical conditions. However, BUN is not specifically used to diagnose rheumatoid arthritis.
C. Urinalysis
Urinalysis is a test that examines the urine for various substances, including cells, bacteria, and chemicals. It can be used to diagnose a variety of conditions, including urinary tract infections, kidney disease, and diabetes. However, urinalysis is not typically used to diagnose rheumatoid arthritis.
D. Erythrocyte sedimentation rate (ESR)
Erythrocyte sedimentation rate (ESR) is a blood test that measures how quickly red blood cells settle at the bottom of a test tube. A high ESR can indicate inflammation in the body. ESR is often elevated in people with rheumatoid arthritis, as it is a marker of inflammation.
E. White blood cell count
White blood cell count (WBC) is a blood test that measures the number of white blood cells in the blood. White blood cells are part of the immune system and help fight infection. A high WBC count can indicate an infection or inflammation. WBC count can be elevated in people with rheumatoid arthritis, as it is a marker of inflammation.
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Full Explanation
Choice A rationale:
Antinuclear antibody (ANA) titer is a blood test that detects the presence of antinuclear antibodies, which are autoantibodies that target the body's own tissues. These antibodies are often present in people with autoimmune diseases, including rheumatoid arthritis.
While a positive ANA test does not definitively diagnose rheumatoid arthritis, it can support a diagnosis when considered alongside other clinical findings and laboratory tests.
Choice B rationale:
Blood urea nitrogen (BUN) is a blood test that measures the amount of urea nitrogen in the blood. Urea nitrogen is a waste product that is produced when the body breaks down proteins.
BUN levels can be elevated in people with kidney disease, dehydration, or certain other medical conditions. However, BUN is not specifically used to diagnose rheumatoid arthritis.
Choice C rationale:
Urinalysis is a test that examines the urine for various substances, including cells, bacteria, and chemicals.
It can be used to diagnose a variety of conditions, including urinary tract infections, kidney disease, and diabetes. However, urinalysis is not typically used to diagnose rheumatoid arthritis.
Choice D rationale:
Erythrocyte sedimentation rate (ESR) is a blood test that measures how quickly red blood cells settle at the bottom of a test tube.
A high ESR can indicate inflammation in the body.
ESR is often elevated in people with rheumatoid arthritis, as it is a marker of inflammation.
Choice E rationale:
White blood cell count (WBC) is a blood test that measures the number of white blood cells in the blood. White blood cells are part of the immune system and help fight infection.
A high WBC count can indicate an infection or inflammation.
WBC count can be elevated in people with rheumatoid arthritis, as it is a marker of inflammation.
Similar Questions
A nurse is preparing to remove a patient’s urinary catheter.
After performing hand hygiene, what should the nurse do next?
A. Position the client supine.
Positioning the client supine is not the immediate next step after performing hand hygiene when preparing to remove a patient’s urinary catheter. While it is important to ensure the patient is in a comfortable and appropriate position for the procedure, the immediate next step should be focused on ensuring the area is clean to prevent infection.
B. Cleanse the perineal area with an antiseptic.
After performing hand hygiene, the nurse should cleanse the perineal area with an antiseptic. This is to ensure that the area is clean before proceeding with the removal of the urinary catheter. It helps to prevent the introduction of bacteria into the urinary tract, which could lead to a urinary tract infection. The use of an antiseptic is recommended to kill any potential pathogens that may be present.
C. Deflate the balloon halfway and then pull out the catheter.
Deflating the balloon halfway and then pulling out the catheter is not the immediate next step after performing hand hygiene. This step is usually done later in the process. Before deflating the balloon, it is important to ensure that the area is clean to prevent infection. Moreover, deflating the balloon halfway could potentially cause discomfort or injury to the patient. The balloon should be fully deflated before the catheter is removed.
D. Have the client bear down during removal.
Having the client bear down during removal is not the immediate next step after performing hand hygiene. This action might be suggested during the actual removal of the catheter to aid in the process, but it is not the immediate next step. The focus right after hand hygiene should be on cleaning the area to prevent infection.
Full Explanation
Choice A rationale:
Positioning the client supine is not the immediate next step after performing hand hygiene when preparing to remove a patient’s urinary catheter. While it is important to ensure the patient is in a comfortable and appropriate position for the procedure, the immediate next step should be focused on ensuring the area is clean to prevent infection.
Choice B rationale:
After performing hand hygiene, the nurse should cleanse the perineal area with an antiseptic. This is to ensure that the area is clean before proceeding with the removal of the urinary catheter. It helps to prevent the introduction of bacteria into the urinary tract, which could lead to a urinary tract infection. The use of an antiseptic is recommended to kill any potential pathogens that may be present.
Choice C rationale:
Deflating the balloon halfway and then pulling out the catheter is not the immediate next step after performing hand hygiene. This step is usually done later in the process. Before deflating the balloon, it is important to ensure that the area is clean to prevent infection. Moreover, deflating the balloon halfway could potentially cause discomfort or injury to the patient. The balloon should be fully deflated before the catheter is removed.
Choice D rationale:
Having the client bear down during removal is not the immediate next step after performing hand hygiene. This action might be suggested during the actual removal of the catheter to aid in the process, but it is not the immediate next step. The focus right after hand hygiene should be on cleaning the area to prevent infection.
A nurse is instructing a newly licensed nurse on how to obtain a fecal occult blood test from a patient.
What information should the nurse include?
A. Apply four drops of developing solution to each stool specimen.
Applying four drops of developing solution to each stool specimen is incorrect. Typically, the test requires two drops of solution. Following manufacturer instructions ensures accurate results and prevents unnecessary waste or inaccurate readings.
B. Use toilet paper to transfer the stool specimen.
Using toilet paper to transfer the stool specimen is improper. Stool should be collected using the provided applicator stick to avoid contamination, ensuring the accuracy of the fecal occult blood test.
C. Wait 30 seconds after applying the developing solution to obtain the results.
Waiting 30 seconds after applying the developing solution allows the chemical reaction to complete, ensuring accurate detection of any occult blood present in the stool sample.
D. Collect two stool specimens from the same area of the stool.
Collecting two stool specimens from the same area increases the risk of missing occult blood present in different parts of the stool. Sampling from multiple areas enhances test accuracy and ensures comprehensive results.
Full Explanation
The correct answer is Choice C.
Choice A rationale: Applying four drops of developing solution to each stool specimen is incorrect. Typically, the test requires two drops of solution. Following manufacturer instructions ensures accurate results and prevents unnecessary waste or inaccurate readings.
Choice B rationale: Using toilet paper to transfer the stool specimen is improper. Stool should be collected using the provided applicator stick to avoid contamination, ensuring the accuracy of the fecal occult blood test.
Choice C rationale: Waiting 30 seconds after applying the developing solution allows the chemical reaction to complete, ensuring accurate detection of any occult blood present in the stool sample.
Choice D rationale: Collecting two stool specimens from the same area increases the risk of missing occult blood present in different parts of the stool. Sampling from multiple areas enhances test accuracy and ensures comprehensive results.
A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury.
Which statement by the adolescent indicates a need for further teaching?
A. I do my wheelchair exercises sitting in my chair.
The statement “I do my wheelchair exercises sitting in my chair” is correct. Wheelchair exercises are designed to be performed while seated in a wheelchair. They help to maintain muscle strength and flexibility, which is crucial for individuals with paralysis.
B. I use a suppository every night to have a bowel movement.
The statement “I use a suppository every night to have a bowel movement” is also correct. Individuals with paralysis often have difficulty with bowel movements due to lack of muscle control. Using a suppository can stimulate the rectum and induce a bowel movement. Choice C rationale: The statement “I need to catheterize myself twice a day” indicates a need for further teaching. Individuals with paralysis from the waist down following a spinal cord injury typically need to perform intermittent self-catheterization every 4-6 hours, not just twice a day. This helps to prevent urinary tract infections and bladder overdistension.
C. I need to catheterize myself twice a day.
D. I carry a water bottle with me because I drink a lot of water.
The statement “I carry a water bottle with me because I drink a lot of water” is correct. Drinking plenty of water is important for overall health and can help prevent urinary tract infections, which are common in individuals who self-catheterize.
Full Explanation
Choice A rationale:
The statement “I do my wheelchair exercises sitting in my chair” is correct. Wheelchair exercises are designed to be performed while seated in a wheelchair. They help to maintain muscle strength and flexibility, which is crucial for individuals with paralysis.
Choice B rationale:
The statement “I use a suppository every night to have a bowel movement” is also correct. Individuals with paralysis often have difficulty with bowel movements due to lack of muscle control. Using a suppository can stimulate the rectum and induce a bowel movement. Choice C rationale:
The statement “I need to catheterize myself twice a day” indicates a need for further teaching. Individuals with paralysis from the waist down following a spinal cord injury typically need to perform intermittent self-catheterization every 4-6 hours, not just twice a day. This helps to prevent urinary tract infections and bladder overdistension.
Choice D rationale:
The statement “I carry a water bottle with me because I drink a lot of water” is correct. Drinking plenty of water is important for overall health and can help to prevent urinary tract infections, which are common in individuals who self-catheterize.