A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take?

Wear sterile gloves to collect the specimen from the client.

Obtain the specimen immediately upon the client waking up.

Wait 1 day to collect the specimen if the client cannot provide sputum.

Ask the client to provide 15 to 20 mL of sputum into the container.

Answer and Explanation

The Correct Answer is B

A. Clean gloves (not sterile) are sufficient for collecting a sputum sample.

B. The best time to collect a sputum specimen is immediately upon waking because secretions accumulate overnight, making it easier to obtain a sample.

C. Waiting a day delays diagnosis and treatment; other techniques can help induce sputum production.

D. Typically, 5 to 10 mL of sputum is sufficient for diagnostic testing.

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Correct Answer is ["A","B","C","D"]

Explanation

A. Abdominal circumference: The increase in abdominal circumference by 1 cm (0.4 in) since the prior assessment is concerning and may indicate a complication such as abdominal distension, which could be a sign of necrotizing enterocolitis (NEC) or other gastrointestinal issues. NEC is a serious condition that is common in preterm infants, especially those receiving enteral feedings.

B. Gestational age: Being born at 34 weeks gestation is a significant risk factor. Prematurity increases the risk for complications like respiratory distress syndrome (RDS), infections, and feeding difficulties. Preterm infants are also at risk for problems with thermoregulation, which is why the neonate is on a radiant warmer.

C. Respiratory distress: The presence of substernal retractions, nasal flaring, and an elevated respiratory rate (70/min) indicates respiratory distress. Preterm neonates, especially those born at 34 weeks, are at risk for RDS due to insufficient surfactant production, which can lead to difficulty breathing and hypoxemia.

D. UAC: The umbilical arterial catheter (UAC) is commonly used for monitoring blood pressure and obtaining blood samples in neonates. However, it carries a risk for complications such as infection, thrombosis, and injury to blood vessels. This is an invasive device that could contribute to complications.

E. Feeding method (Continuous breast milk feedings via OG tube): Although feeding via an orogastric tube is a standard method for preterm neonates, it does not pose an immediate risk factor in this case. The method of feeding itself is not a complication risk. However, complications like feeding intolerance or aspiration can arise, which would require further monitoring.

G. 5-minute Apgar score: A 5-minute Apgar score of 7 is considered an acceptable score for a neonate. Although it indicates some initial difficulty, this score does not present a significant risk factor for complications by itself. A lower score would be more concerning, but a score of 7 typically suggests the neonate is transitioning well.

A. Client reports auditory hallucinations B. Inability to carry out a simple task C. Moves quickly from one idea to the next D. Client expresses illusions of grandeur

Correct Answer is B

Explanation

A. Auditory hallucinations are more commonly associated with psychosis rather than a depressive episode.

B. Inability to carry out simple tasks is a hallmark of a depressive episode due to low energy, poor concentration, and feelings of hopelessness.

C. Moving quickly from one idea to the next (flight of ideas) is characteristic of a manic episode, not a depressive episode.

D. Illusions of grandeur occur during manic episodes, not depressive episodes.

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A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","C","D"]

Explanation

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Correct Answer is B

Explanation

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