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”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Bisacodyl is a stimulant laxative commonly used to treat constipation. However, it is important to educate the client about the potential risks associated with chronic laxative use. The statement regarding electrolyte imbalance is important because excessive or prolonged use of laxatives can lead to electrolyte disturbances, such as low potassium levels (hypokalemia), which can have adverse effects on various body functions.
"Daily bowel movements are necessary for good intestinal health": While regular bowel movements are generally desirable, stating that daily bowel movements are necessary for good intestinal health is an overgeneralization. Bowel movement frequency can vary among individuals, and it is important to consider other factors such as diet, hydration, and overall health.
"Chronic use of laxatives can lead to a tear in the rectal mucosa": While chronic use of laxatives can lead to complications such as dependence and potential damage to the digestive system, specifically mentioning a tear in the rectal mucosa (rectal mucosal injury) is not the most commonly associated concern.
"Decrease your intake of high-fiber foods": It is generally recommended to increase fiber intake for individuals with constipation. Decreasing high-fiber foods would counteract the benefits of dietary fiber in promoting regular bowel movements and alleviating constipation.
Correct Answer is B
Explanation
After administering lactulose to a client with cirrhosis, the nurse should monitor for the adverse effects of diarrhea. Lactulose is a laxative commonly used in the treatment of hepatic encephalopathy, which can occur in individuals with cirrhosis. One of the intended effects of lactulose is to promote bowel movements and reduce the absorption of ammonia in the gut, thus helping to manage hepatic encephalopathy.
While lactulose can cause adverse effects such as diarrhea, it is not typically associated with peripheral edema. Peripheral edema is often seen in cirrhosis due to fluid retention caused by liver dysfunction.
Dry mouth and headache are less commonly associated with lactulose use and are not typically the primary adverse effects to monitor for in this scenario.
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