A nurse is preparing to collect a stool specimen from a client for laboratory testing. Which of the following actions should the nurse take when collecting the specimen?

Transfer the specimen to a cup without it touching the outside of the container.

Wait for 4 hr before sending the specimen to the laboratory.

Collect at least 7.62 cm (3 in) of the client's stool.

Avoid collecting the specimen from areas of the stool that contain blood.

Answer and Explanation

The Correct Answer is A

A. Transfer the specimen to a cup without it touching the outside of the container.: This maintains a clean environment and prevents the spread of microorganisms to others.

B. Wait for 4 hr before sending the specimen to the laboratory.: Specimens should be sent to the lab immediately to ensure accurate results, as changes in temperature and pH can degrade the sample.

C. Collect at least 7.62 cm (3 in) of the client's stool.: Usually, 1 inch (2.5 cm) of formed stool or 15–30 mL of liquid stool is sufficient for testing.

D. Avoid collecting the specimen from areas of the stool that contain blood.: Incorrect. If blood, mucus, or pus is present, these areas should be included in the specimen as they are most likely to contain pathogens.

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Correct Answer is C

Explanation

A. "He appears anxious about the transfer.": This is a subjective observation. While helpful, it is not the most critical clinical data point.

B. "He is voiding adequately.": This is vague. A transfer report should include specific data (e.g., "Voided 400 mL of clear yellow urine this shift").

C. "He is allergic to sulfa.": Safety information, particularly allergies, is the most critical information to communicate to the receiving nurse to prevent a life-threatening medication error.

D. "His partner has been visiting.": This is social information and, while helpful for holistic care, is not a priority for a clinical transfer report.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Correct answers: At 1000 the nurse enters the client's room. The first action the nurse should take is call for assistance followed by turn the client to their side.

i. call for assistance: According to the nursing process, once a seizure begins (the ictal phase), the nurse must ensure they have help to manage the client's safety and monitor the event. The nurse should stay with the client but call for another staff member to bring emergency equipment or notify the provider.

ii. turn the client to their side: This is the priority safety intervention during a generalized tonic-clonic seizure. Turning the client to a lateral position helps maintain a patent airway and prevents aspiration of oral secretions or vomitus.

Rationale for incorrect answers:

remove the pillows: While removing pillows can help prevent airway occlusion if the head is hyper-flexed, calling for help and positioning the client on their side are higher priorities in the sequence of emergency management.

reorient the client: This occurs during the postictal phase (after the seizure has ended) when the client is regaining consciousness, not during the active seizure at 1000.

administer anticonvulsant medications: While medications like IV lorazepam may be indicated if a seizure is prolonged (status epilepticus), the immediate physical safety and airway management are the first nursing actions.

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A nurse is preparing to collect a stool specimen from a client for laboratory testing. Which of the following actions should the nurse take when collecting the specimen?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?

Correct Answer is C

Explanation

A nurse is assisting in the care of a client. Complete the following sentence by using the lists of options. At 1000 the nurse enters the client's room. The first action the nurse should take is _____ followed by _____ .

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

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