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.
Choice A rationale: Maintaining bed elevation at 20 degrees is not recommended. The recommended bed elevation for patients receiving enteral tube feedings is at least 30 to 45 degrees.This is to prevent aspiration of the feeding solution into the lungs.
Choice B rationale: Flushing the tubing with 30 mL of water every 4 hours is a recommended practice.This helps to maintain the patency of the feeding tube and prevent clogging.
Choice C rationale: Checking for gastric residual every 12 hours is not sufficient.For patients receiving continuous tube feedings, gastric residual volume (GRV) should be monitored every 4 hours.This helps to assess tolerance to the feeding and prevent complications such as aspiration.
Choice D rationale: Placing enough formula in the container to last 18 hours is not recommended.For an open system, the formula should be replaced every 4 hours to prevent bacterial growth.
Correct Answer is D
No explanation
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