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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A.Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.

B.Applying lubricant to the site is not necessary or recommended. The gastrostomy tube should be kept clean and dry. If any secretions or debris are present, they should be gently cleaned with mild soap and water, followed by thorough rinsing and drying.

C.Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.

D.Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.

A. Sun protection is not necessary when using self-tanning creams. B. The risk of injury from firearms decreases as children enter adolescence. C. Driving skills can be impaired when friends are present. D. Medroxyprogesterone provides protection against gonorrhea.

Correct Answer is C

Explanation

Choice A rationale:

Sun protection is necessary when using self-tanning creams. These products do not provide protection against harmful UV rays. Failure to use sun protection measures, such as sunscreen and protective clothing, can lead to skin damage and increase the risk of skin cancer.

Choice B rationale:

The risk of injury from firearms does not necessarily decrease as children enter adolescence. Adolescents, like any other age group, should be educated about the dangers of firearms and the importance of firearm safety. Access to firearms should be restricted, and proper storage and education about safe handling are essential.

Choice C rationale:

Driving skills can be impaired when friends are present, especially for new and inexperienced drivers. Peer pressure and distractions from friends can lead to risky behaviors and impaired judgment, increasing the risk of accidents. It is crucial to educate adolescents about the importance of focused and responsible driving.

Choice D rationale:

Medroxyprogesterone is a hormonal contraceptive and does not provide protection against gonorrhea or other sexually transmitted infections (STIs). Safe sex practices, including the use of barrier methods such as condoms, are essential in preventing the transmission of STIs.

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A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take?

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A nurse is collecting a sputum specimen from a client who has tuberculosis.
Which of the following actions should the nurse take?