A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Wipe the sample port with an alcohol wipe and let the alcohol dry.
Clamp the catheter tubing distal to the sampling port for 15 min.
Attach a sterile needleless syringe to the sample port and aspirate the specimen
Document in the client's electronic medical record that the specimen was sent to the laboratory.
Empty the urine into a sterile container labeled with the client identifiers
The Correct Answer is B, A, C, E, D
Clamp the catheter tubing distal to the sampling port for 15 min. By clamping the tubing distal to the sampling port, it allows urine to accumulate in the tubing, ensuring that the urine specimen obtained is fresh and not from the stagnant urine that has been sitting in the tubing.
Wipe the sample port with an alcohol wipe and let the alcohol dry. Cleaning the sampling port with an alcohol wipe helps reduce the risk of introducing contaminants into the sample during collection, ensuring a more sterile procedure.
Attach a sterile needleless syringe to the sample port and aspirate the specimen. Using a sterile syringe prevents contamination and allows for the collection of a clean urine sample directly from the catheter tubing, maintaining the sterility of the specimen.
Empty the urine into a sterile container labeled with the client identifiers. Transferring the collected urine into a sterile container labeled with the client's identifiers ensures proper identification and handling of the specimen for laboratory analysis.
Document in the client's electronic medical record that the specimen was sent to the laboratory. Documenting in the client's medical record ensures that there is a clear record of the specimen collection, its handling, and its dispatch to the laboratory for analysis, maintaining proper documentation and continuity of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A"]
Explanation
a. Have the client wear a surgical mask during transport. This is the appropriate intervention to prevent the spread of the influenza virus when the client needs to be transported within the healthcare facility. Influenza is primarily spread through respiratory droplets, so wearing a surgical mask helps to contain these droplets.
b. Wear an N95 mask while providing care to the client. An N95 mask is generally not required for influenza. Standard precautions, including wearing a surgical mask when within close proximity to the client, are usually sufficient.
c. Administer an influenza immunization to the client. It is not appropriate to administer the influenza vaccine to a client who is already infected with the influenza virus.
d. Place the client in a negative airflow room. Negative airflow rooms are typically reserved for airborne diseases such as tuberculosis. Influenza, which spreads via droplets, does not require this level of isolation.
Correct Answer is D
Explanation
Choice A Reason:
Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL) is incorrect. Bilirubin levels within the normal range typically indicate normal liver function. The value of 1.0 mg/dL falls within the expected range, so it doesn't raise immediate concerns regarding the need for a liver biopsy.
Choice B Reason:
Aspartate aminotransferase 34 units/L (0 to 34 units/L) is incorrect. Aspartate aminotransferase (AST) is an enzyme found in various tissues, including the liver, heart, muscles, and red blood cells. While a value of 34 units/L is at the upper limit of the normal range, it's still within the expected range and doesn't typically prompt immediate concern for the need for a biopsy.
Choice C Reason:
Ammonia 55 mcg/dL (10 to 80 mcg/dL ) is incorrect. Ammonia levels can rise in cases of liver dysfunction. The level of 55 mcg/dL falls within the reference range, indicating normal or near-normal ammonia levels, which doesn't usually necessitate an urgent liver biopsy.
Choice D Reason:
Platelets 60,000/mm3 (150,000 to 400,000/mm3) is correct. Platelets are crucial for blood clotting. A significantly low platelet count, such as 60,000/mm3, termed thrombocytopenia, can indicate compromised clotting ability, which might pose a risk of bleeding during or after a liver biopsy. In the context of a liver biopsy, a low platelet count warrants attention and consideration before proceeding with the procedure to prevent excessive bleeding or complications.
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