A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take?

Wear sterile gloves when collecting the sample.

Discard samples that contain urine.

Collect three samples from a single bowel movement.

Take the sample from the outer edge of formed stool.

Answer and Explanation

The Correct Answer is B

Choice A reason: While wearing gloves is a standard precaution to prevent contamination and protect the nurse from potential pathogens, the gloves used for collecting a guaiac smear sample do not need to be sterile. Clean, non-sterile gloves are typically sufficient for this procedure.

Choice B reason: It is crucial to discard any samples that contain urine because urine can interfere with the results of the fecal occult blood test (FOBT). The presence of urine can cause false positives due to the peroxidase activity in urine, which can lead to unnecessary further testing.

Choice C reason: Collecting three samples from a single bowel movement is not recommended. Instead, it is advised to collect samples from three separate bowel movements to increase the likelihood of detecting intermittent bleeding, which is common in conditions like colorectal cancer.

Choice D reason: Taking the sample from the outer edge of formed stool is not the best practice. The sample should be taken from different areas of the stool to ensure a representative sample, as blood may not be uniformly distributed throughout the stool.

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Correct Answer is C

Explanation

Choice A reason: A heart rate of 60/min is within the normal range for an adult, and while it may be considered on the lower end, it is not in itself an indication to increase dopamine dosage. Dopamine is used to increase heart rate and cardiac output, but a rate of 60/min does not typically warrant an increase in dosage unless accompanied by other signs of inadequate perfusion.

Choice B reason: An oxygen saturation of 95% is within the normal range for arterial blood gases and is not an indication to increase dopamine dosage. Oxygen saturation reflects the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen.

Choice C reason: A blood pressure of 90/50 mm Hg is considered low and can be an indication for increasing the dopamine dosage in a client with hypovolemic shock. Dopamine increases blood pressure by vasoconstriction and increasing cardiac output, which is critical in managing shock.

Choice D reason: A respiratory rate of 14/min is within the normal range for adults and is not an indication to increase dopamine dosage. The respiratory rate should be monitored for changes that could indicate worsening of the client's condition, but on its own, it does not dictate adjustments to dopamine therapy.

A. Instruct the client to expect tingling in their extremities. B. Measure blood glucose every 2 hours. C. Limit the client's fluid intake. D. Instruct the client to lie flat.

Correct Answer is D

Explanation

Choice A reason: Instructing the client to expect tingling in their extremities is not a standard post-lumbar puncture care instruction. Tingling may be a sign of nerve irritation or damage, which is not an expected outcome and should be reported if it occurs.

Choice B reason: Measuring blood glucose every 2 hours is not related to post-lumbar puncture care unless the client has a specific condition that requires such monitoring. Post-lumbar puncture care focuses on preventing complications such as headaches and monitoring for signs of infection or bleeding.

Choice C reason: Limiting the client's fluid intake is not advised following a lumbar puncture. In fact, increasing fluid intake can help prevent the occurrence of post-lumbar puncture headaches, which are a common complication. Adequate hydration helps replenish cerebrospinal fluid and reduce headache severity.

Choice D reason: Instructing the client to lie flat is the correct action. After a lumbar puncture, it is recommended that the client lies flat for several hours to prevent the leakage of cerebrospinal fluid from the puncture site, which can lead to a spinal headache. Lying flat helps maintain normal cerebrospinal fluid pressure and reduces the risk of headache.

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A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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