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 B

Explanation

Choice A rationale:

Recent myocardial infarction is not a contraindication for warfarin administration. Warfarin is often prescribed for patients with a history of myocardial infarction to prevent clot formation and reduce the risk of stroke.

Choice B rationale:

Recent eye surgery is a contraindication for the administration of warfarin. Warfarin can increase the risk of bleeding, which is particularly concerning after eye surgery due to the delicate nature of ocular tissues. Using anticoagulants in this scenario can lead to severe complications, including vision loss.

Choice C rationale:

Thrombophlebitis, inflammation of a vein with clot formation, is not a contraindication for warfarin administration. In fact, anticoagulants like warfarin are commonly prescribed to prevent the extension of clots and reduce the risk of complications associated with thrombophlebitis.

Choice D rationale:

Breast cancer is not a direct contraindication for warfarin administration. However, the decision to use anticoagulants in patients with a history of breast cancer should be made carefully, considering individual factors such as the stage of cancer, ongoing treatment, and overall risk of thromboembolic events.

A. Use a syringe to allow the medications to flow by gravity. B. Flush the NG tube with 5 mL water. C. Dissolve the medications together. D. Add medication directly to enteral feeding.

Correct Answer is A

Explanation

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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?

Nursing Test Bank

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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?