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 C
Explanation
Choice A rationale:
Soaking in a warm bath every day is not a preventative measure for chronic urinary tract infections. Warm baths might provide temporary relief for discomfort but do not prevent UTIs.
Choice B rationale:
Taking an oral estrogen supplement is not a standard preventative measure for chronic urinary tract infections. Estrogen therapy might be recommended for postmenopausal women with recurrent UTIs, but it's not a general preventive method for all women.
Choice C rationale:
"Drink 2 liters of water per day." This is the correct answer. Staying well-hydrated is essential to prevent urinary tract infections. Drinking an adequate amount of water can help flush out bacteria from the urinary system, reducing the risk of infections. The normal range for daily water intake varies but is generally around 2-3 liters or eight 8-ounce glasses per day.
Choice D rationale:
Emptying the bladder every 6 hours is a good practice, but it might not be sufficient for someone prone to chronic UTIs. Regular and frequent urination can help prevent the buildup of bacteria in the urinary tract. However, specific time intervals might vary from person to person, so a fixed 6-hour rule might not apply to everyone.
Correct Answer is B
Explanation
The correct answer is: b. A room containing personal belongings.
Choice A rationale: A room without a window may lead to disorientation and a lack of natural light, which can disrupt the client's circadian rhythm, contributing to sleep disturbances and mood alterations. Adequate exposure to natural light helps regulate the body's internal clock and promotes a sense of well-being. Furthermore, natural light exposure has been linked to improved cognitive function and mood stability in individuals with cognitive impairments. Therefore, choosing a room with a window is essential for optimizing the client's therapeutic environment.
Choice B rationale: A room containing personal belongings is crucial for creating a therapeutic environment for a cognitively impaired client. Familiar items provide a sense of security and continuity, reducing anxiety and agitation. These belongings serve as anchors to the client's past experiences and identity, facilitating reminiscence therapy and promoting emotional connection. By surrounding the client with familiar objects, the nurse fosters a sense of autonomy and self-expression, empowering the client to engage in meaningful activities and maintain a sense of personal agency.
Choice C rationale: While proximity to the nursing station may facilitate monitoring and prompt intervention in case of emergencies, a room adjacent to the nursing station can also expose the client to constant noise and disruptions. Excessive auditory stimuli can overwhelm a cognitively impaired individual, leading to sensory overload and exacerbating confusion and disorientation. Moreover, the lack of privacy in such a location may compromise the client's dignity and autonomy, hindering their ability to engage in personal activities and interactions. Therefore, placing the client in a quieter, more secluded environment away from the nursing station is preferable for promoting a therapeutic atmosphere conducive to rest and relaxation.
Choice D rationale: Dim lighting poses significant risks for cognitively impaired clients, as it impairs visual perception and increases the likelihood of accidents and falls. Inadequate lighting compromises safety by obscuring obstacles and hazards in the environment, heightening the risk of injuries and fractures. Additionally, dimly lit spaces can exacerbate feelings of fear and anxiety, particularly in individuals with cognitive impairments who may already experience sensory processing difficulties. Bright lighting, on the other hand, enhances visibility and spatial orientation, promoting independence and confidence in daily activities. Therefore, ensuring sufficient illumination in the client's room is essential for mitigating safety hazards and optimizing their overall well-being.
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