A charge nurse overhears a newly licensed nurse providing instructions to a female client on the proper steps to collect a midstream urine specimen. Which of the following statements made by the newly licensed nurse requires the charge nurse to intervene?

"Use the provided towelette to cleanse the area by moving in a back-and-forth motion."

"Start the flow of urine before passing the container under the stream to collect the specimen."

"It will be easier to use your nondominant hand to spread the labia."

"Remove the specimen container before stopping the stream of urine”

Answer and Explanation

The Correct Answer is B

This statement is incorrect and requires correction because it suggests starting the flow of urine before positioning the collection container, which can result in contamination of the specimen. The correct procedure for collecting a midstream urine specimen involves the following steps:

1. Provide the client with a clean urine specimen container.

2. Instruct the client to cleanse the genital area using a provided towelette or antiseptic wipes, wiping from front to back.

3. Instruct the client to start urinating into the toilet or bedpan.

4. As the urine stream continues, the client should pass the collection container into the stream to collect the midstream specimen.

5. Once an adequate amount of urine has been collected (as per the laboratory's instructions), the client should remove the container from the stream of urine. 6. The client can then complete urinating into the toilet or bedpan.

The other statements made by the newly licensed nurse are correct:

"Use the provided towelette to cleanse the area by moving in a back-and-forth motion": This statement correctly instructs the client to cleanse the genital area before collecting the urine specimen.

"It will be easier to use your nondominant hand to spread the labia": This statement is correct as it suggests using the nondominant hand to facilitate the collection process.

"Remove the specimen container before stopping the stream of urine": This statement is correct as it indicates that the container should be removed before completing urination.

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Free Nursing Study Resources

Correct Answer is C,A,D,E,B

Explanation

To pour the sterile solution onto a piece of gauze, the nurse should perform the steps in the following order:

1. Pick up the bottle with the label facing his palm.

2. Remove the bottle cap.

3. Pour 1 to 2 mL into a receptacle.

4. Pour the solution onto the gauze.

5. Place the bottle cap inside up on a clean surface.

It is important to maintain sterility throughout the procedure to prevent contamination. By following this order, the nurse ensures that the solution is poured onto the gauze while minimizing the risk of contamination. Placing the bottle cap inside up on a clean surface after removing it helps maintain the sterility of the cap as well.

A. Insert the tubing about 15 cm (6 in) into the anus. B. Hang the enema container 61 cm (24 in) above the anus. C. Assist the client to the left Sims' position. D. Put on sterile gloves.

Correct Answer is C

Explanation

The left Sims' position (also known as the left lateral position) is the appropriate position for administering a soapsuds enema. This position allows for better visualization and access to the rectum and facilitates the flow of the enema solution.

The other options mentioned are incorrect:

Inserting the tubing about 15 cm (6 in) into the anus: The specific depth of insertion may vary depending on the client, but the general guideline is to insert the tubing about 3 to 4 inches into the rectum for an adult. 15 cm (6 in) would be excessively deep and could cause discomfort or injury.

Hanging the enema container 61 cm (24 in) above the anus: The height at which the enema container is hung should be no more than 18-24 inches (45-60 cm) above the anus. Hanging it too high can cause excessive pressure and discomfort during the administration.

Putting on sterile gloves: Sterile gloves are not typically required for the administration of a soapsuds enema. Clean gloves or non-sterile gloves are generally sufficient for this procedure.

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A charge nurse overhears a newly licensed nurse providing instructions to a female client on the proper steps to collect a midstream urine specimen. Which of the following statements made by the newly licensed nurse requires the charge nurse to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assisting a provider with a sterile procedure prepares to pour a sterile solution onto a piece of gauze. In which order should the nurse perform the steps of pouring the solution? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is C,A,D,E,B

Explanation

A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is checking the client's bowel sounds. At which time should the nurse auscultate the client's abdomen?

A nurse is reinforcing teaching with a client who has a new prescription for docusate sodium. The nurse should recognize which of the following statements indicates the client understands the teaching?

A nurse is preparing to administer dextrose 5% in water IV to infuse at 100 mL/60 min. The drop factor on the manual IV tubing is 60 gtt/ml. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)

A nurse is preparing to administer 0.9% sodium chloride (NS) 100 mL IV to infuse over 4 hr. The drip factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number.)

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse identify as a risk factor for this condition?

A nurse is reinforcing teaching with a client who is taking hydrochlorothiazide. Which of the following information should the nurse include in the teaching?

A nurse is collecting data from a client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease?