A nurse is collecting a sputum specimen from a client who has tuberculosis.
Which of the following actions should the nurse take?
Obtain the specimen immediately upon the client waking up.
Ask the client to provide 15 to 20 mL of sputum into the container.
Wear sterile gloves to collect the specimen from the client.
Wait 1 day to collect the specimen if the client cannot provide sputum.
The Correct Answer is A
The correct answer is Choice a.
Choice a rationale: The nurse should obtain the specimen immediately upon the client waking up, as sputum from deep in the lungs is usually more easily collected at this time. Sputum collected upon waking up is more likely to contain secretions from the lower respiratory tract, providing a better sample for tuberculosis diagnosis. This timing maximizes the chance of detecting the bacteria.
Choice b rationale: Choice b is incorrect because the typical volume of sputum needed for testing is about 1 teaspoon (5 mL), not 15 to 20 mL. Collecting such a large volume could be challenging for the client and unnecessary for diagnostic purposes.
Choice c rationale: Choice c is incorrect because while gloves should be worn, they do not need to be sterile, just clean. The use of clean gloves is sufficient to prevent contamination during specimen collection, and sterile gloves are not required for this procedure.
Choice d rationale: Choice d is incorrect because it’s important to try to collect the specimen as soon as possible, not wait a full day. Delaying collection for a day could result in a missed opportunity to diagnose tuberculosis and initiate appropriate treatment promptly. Collecting the specimen promptly maximizes the accuracy of diagnostic testing and facilitates timely intervention for the client's health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Potato pancakes made from potatoes do not contain gluten, making them suitable for someone with celiac disease. Gluten is a protein found in wheat, barley, and rye, so individuals with celiac disease must avoid foods containing these grains.
Choice B rationale:
Wheat crackers contain gluten and are not appropriate for someone with celiac disease. Avoiding gluten is crucial for individuals with this condition to prevent damage to the small intestine.
Choice C rationale:
White flour tortillas are typically made from wheat flour and contain gluten. Individuals with celiac disease should avoid products made from wheat flour to prevent adverse reactions.
Choice D rationale:
Canned barley soup contains barley, which is a gluten-containing grain. Individuals with celiac disease should avoid barley-based products as they contain gluten.
Correct Answer is A
Explanation
Choice A rationale:
The described cardiac rhythm with a wavy baseline, no distinguishable P waves, and an increased heart rate is consistent with atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to an irregular and often rapid heart rate. This rhythm is characterized by the absence of distinct P waves on the ECG.
Choice B rationale:
Ventricular asystole is a flatline on the ECG, indicating the absence of electrical activity in the heart. It is a life-threatening arrhythmia and requires immediate intervention with cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) protocols.
Choice C rationale:
Second-degree heart block is characterized by intermittent failure of atrial electrical impulses to conduct to the ventricles. This results in occasional dropped beats and a varying heart rate. It is not consistent with the described ECG findings in the question.
Choice D rationale:
Sinus tachycardia is a regular, fast heart rate originating from the sinoatrial (SA) node. In sinus tachycardia, P waves are present, indicating that the electrical impulses originate in the SA node. The described ECG findings do not match the characteristics of sinus tachycardia.
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