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 B
Explanation
The correct answer is choice b. “I will hang a new bag of TPN and IV tubing every 24 hours.”
Choice A rationale:
Monitoring the client’s blood glucose level every 8 hours is important, but it is not the best indicator of understanding the TPN procedure. Blood glucose levels should be monitored regularly, but the frequency can vary based on the client’s condition and physician’s orders.
Choice B rationale:
Hanging a new bag of TPN and IV tubing every 24 hours is correct. This practice helps prevent infection and ensures the client receives the correct formulation of nutrients.
Choice C rationale:
Increasing the rate of the TPN infusion to ensure the correct amount is given is incorrect. The rate of TPN infusion should be strictly controlled and adjusted only by a physician’s order to prevent complications such as hyperglycemia or fluid overload.
Choice D rationale:
Obtaining the client’s weight every other day is important for monitoring nutritional status, but it does not directly indicate an understanding of the TPN procedure. Daily weights are often recommended to closely monitor the client’s response to TPN.
Correct Answer is D
Explanation
The correct answer is D. The nurse should measure the client's vital signs first to assess for any injuries or complications from the fall, such as bleeding, shock, or head trauma. The nurse should then notify the provider and document the fall in the client's medical record. Completing an incident report is also important, but it is not the first action that the nurse should take.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.