which of the following is most true about the esr test

NCLEX-RN

NCLEX RN Predictor Exam

1. What is the MOST ACCURATE statement regarding the ESR test?

A. The results are diagnostic for certain conditions.
B. Abnormal results are indicative of a potentially fatal illness.
C. Abnormal results should be followed by additional testing.
D. Results are reported in millimeters per hour.

Correct answer: C

Rationale: The erythrocyte sedimentation rate (ESR) is a non-specific screening test for inflammation in the body. It is not used as a definitive diagnostic tool for specific conditions. When ESR results are abnormal, they indicate the presence of inflammation, which can be caused by various reasons. Therefore, abnormal results should be followed by additional testing to determine the underlying cause. The ESR test measures the rate at which red blood cells settle in a vertical tube over the span of one hour, and results are reported in millimeters per hour. Choice A is incorrect because ESR results are not solely diagnostic for any specific condition. Choice B is incorrect as abnormal ESR results do not directly indicate a potentially fatal illness without further investigation. Choice D is incorrect as the results are reported in millimeters per hour, not per minute.

2. After change-of-shift report, which patient should the nurse assess first?

A. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet
B. 28-year-old with a history of a lung transplant and a temperature of 101 F (38.3 C)
C. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain
D. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

Correct answer: D

Rationale: The patient with lung cancer and tracheal deviation after a subclavian catheter insertion should be assessed first. Tracheal deviation can indicate tension pneumothorax, a life-threatening condition that requires immediate intervention to prevent inadequate cardiac output or hypoxemia. While the other patients also need assessment, the potential for tension pneumothorax in the patient with tracheal deviation necessitates urgent attention to prevent complications.

3. Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao. Which statement most accurately reflects this philosophy's view of "health"??

A. A person is able to work and produce.
B. A person is happy, stable, and feels good.
C. All aspects of the person are in perfect balance.
D. A person is able to care for others and function socially.

Correct answer: C

Rationale: In the yin/yang theory rooted in ancient Chinese philosophy, health is believed to exist when all aspects of a person are in perfect balance. This includes physical, mental, emotional, and spiritual well-being. Choice C accurately reflects this philosophy's view of health. Choices A, B, and D do not capture the essence of the yin/yang theory. Being able to work and produce, being happy and stable, or caring for others and functioning socially, while important, do not encompass the holistic balance emphasized in the yin/yang theory.

4. A client is complaining of pain in his right hand after surgery. The IV in his hand has slowed down, and the skin around the site is reddened and cool. The client reports localized pain in the hand and fingers. What is the most likely cause of this client's pain?

A. The client's IV is infiltrated
B. The client is experiencing phlebitis from the last drug administered
C. The client has a blood clot developing in the distal arteries of the wrist
D. The client's pain is associated with myocardial ischemia and he is having a heart attack

Correct answer: A

Rationale: Pain, cool skin, and edema at an IV injection site indicate IV infiltration. The reddened and cool skin around the IV site, along with localized pain and a slowed IV drip rate, are classic signs of infiltration. Infiltration occurs when IV fluids or medications enter the surrounding tissues instead of the vein, leading to potential tissue damage. Phlebitis is inflammation of a vein, not infiltration. A blood clot in the distal arteries of the wrist would not cause these specific symptoms. Myocardial ischemia and heart attack are unrelated to the client's localized hand pain and IV issues.

5. The instructor is teaching a class on basic assessment skills. Which of the following statements is true regarding the stethoscope and its use?

A. Slope of the earpieces should point forward toward the examiner's nose.
B. It blocks out extraneous room noise but does not magnify sound.
C. The tubing length should be 14 to 18 inches to prevent sound distortion.
D. Both fit and quality of the stethoscope are important.

Correct answer: B

Rationale: The stethoscope does not magnify sound but effectively blocks out extraneous room noises. The correct orientation of the earpieces is with the slope pointing forward toward the examiner's nose, not posteriorly. The tubing length of a stethoscope should ideally be between 14 to 18 inches (36 to 46 cm) to avoid sound distortion. Using tubing longer than this range can distort sound. Both the fit and quality of the stethoscope are crucial for accurate auscultation and assessment, highlighting their significance in clinical practice. Therefore, the correct answer is that the stethoscope blocks out extraneous room noise but does not magnify sound.