A nurse is collecting a sputum specimen from a client for culture and sensitivity. Which of the following actions should the nurse take?
Collect 2 ml of sputum in an emesis basin
Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection
Swab the oropharynx with a sterile swab
Refrigerate the specimen until the time of transport to the laboratory
The Correct Answer is D
Answer: (D) Refrigerate the specimen until the time of transport to the laboratory
Rationale:
A) Collect 2 ml of sputum in an emesis basin: While it is important to collect an adequate volume of sputum, using an emesis basin is inappropriate for collecting a specimen for culture and sensitivity. Sputum must be collected in a sterile container to avoid contamination, ensuring the accuracy of the culture results.
B) Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection: Using an antiseptic mouthwash before collecting a sputum specimen is not recommended, as it could contaminate the sample with antiseptic agents, potentially affecting the growth of microorganisms in the culture. The client should rinse with plain water instead.
C) Swab the oropharynx with a sterile swab: Swabbing the oropharynx is more appropriate for collecting a throat culture rather than a sputum specimen. Sputum collection requires the client to expectorate mucus from the lower respiratory tract, not from the oropharynx, to obtain an accurate sample for culture and sensitivity.
D) Refrigerate the specimen until the time of transport to the laboratory: Refrigerating the sputum specimen is crucial to preserve the integrity of the sample and inhibit the growth of contaminants before it is transported to the laboratory. This action helps ensure that the results of the culture and sensitivity test are accurate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
c. Periorbital edema.
Explanation: Acute glomerulonephritis is an inflammatory condition affecting the glomeruli of the kidneys. It is commonly characterized by periorbital edema, which is swelling around the eyes. This occurs due to fluid retention and impaired kidney function. Other common manifestations of acute glomerulonephritis include hypertension (increased blood pressure), dark or tea-colored urine (hematuria), decreased urine output, and signs of fluid overload such as edema in the hands, feet, and face.
Option a, decreased blood pressure, is not typically seen in acute glomerulonephritis. Instead, hypertension is a common finding due to fluid retention and increased blood volume.
Option b, pale yellow urine, is not expected in acute glomerulonephritis. Instead, urine may appear dark or
tea-colored due to the presence of blood (hematuria).
Option d, increased urination, is not a characteristic finding in acute glomerulonephritis. Instead, there is often a decrease in urine output or oliguria.
It is important to note that individual presentations may vary, and the nurse should consider the complete clinical picture and the child's specific symptoms when assessing for acute glomerulonephritis.
Correct Answer is A
Explanation
The first action the nurse should plan to perform is to check the client's ability to use the call light. This is essential to ensure that the client can easily communicate with the healthcare team if they need assistance or experience a fall risk situation. By confirming the client's ability to use the call light, the nurse can address any potential communication barriers and ensure that the client has a means to request help promptly.
Explanation for the other options:
b) Document the client's risk in the medical record: While documenting the client's risk in the medical record is important, it is not the first action to be taken. Ensuring the client's immediate safety and ability to request assistance is the priority.
c) Request a referral for physical therapy: Referring the client for physical therapy may be a necessary step to address their impaired mobility and reduce fall risk, but it is not the first action to be performed. Assessing their ability to use the call light takes precedence in order to address immediate safety concerns.
d) Place a gait belt in the client's room: Providing a gait belt is a measure to assist with mobility and falls prevention. However, it should not be the first action. Checking the client's ability to use the call light is more critical to ensure their immediate safety and ability to request help.
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