A nurse is preparing to obtain a sputum specimen for a client. Which of the following actions should the nurse plan to take?

Save the sputum specimen in a clean container.

Collect the sputum specimen after a meal.

Rinse the client's mouth before collecting the specimen.

Obtain the specimen from the client in the evening.

Answer and Explanation

The Correct Answer is C

A. Saving the sputum specimen in a clean container.

While it is important to collect the sputum specimen in a clean, sterile container, simply saving the specimen in a clean container is not sufficient. The nurse needs to actively collect the sputum specimen from the client using proper technique to ensure that it is not contaminated and is suitable for laboratory analysis.

B. Collecting the sputum specimen after a meal.

Collecting a sputum specimen after a meal is not recommended, as it can increase the likelihood of contamination with food particles. It's preferable to collect the specimen before meals or at least 1-2 hours after eating to minimize the risk of contamination and ensure the integrity of the specimen.

C. Rinse the client's mouth before collecting the specimen.

When obtaining a sputum specimen from a client, it's important for the nurse to plan to rinse the client's mouth before collecting the specimen. Rinsing the mouth with water helps to clear any food particles or debris from the oral cavity, ensuring that the sputum sample collected is not contaminated with saliva or food particles. This improves the quality and accuracy of the specimen for laboratory analysis.

D. Obtaining the specimen from the client in the evening.

The timing of specimen collection is not necessarily restricted to the evening. The timing may vary depending on the client's condition and the healthcare provider's orders. It's important to follow the healthcare provider's instructions regarding the timing of specimen collection, which may be based on factors such as the client's symptoms and the diagnostic requirements.

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Correct Answer is A

Explanation

A. Withhold food and liquids until the client's gag reflex returns.

This is the correct action. After a bronchoscopy, the client's throat may be numb or irritated from the procedure, which can temporarily impair the gag reflex. Withholding food and liquids until the gag reflex returns reduces the risk of aspiration, where food or liquid enters the airway instead of the stomach. Aspiration can lead to pneumonia and other serious complications. Therefore, it's essential to assess the client's gag reflex before allowing them to eat or drink.

B. Irrigate the client's throat every 4 hours.

This action is not necessary and may even be harmful. Irrigating the client's throat every 4 hours could further irritate the throat and increase discomfort for the client. Unless specifically ordered by the healthcare provider for a specific reason, such as to remove secretions or debris, routine irrigation of the throat is not recommended after a bronchoscopy.

C. Have the client refrain from talking for 24 hours.

There is typically no need for the client to refrain from talking for 24 hours after a bronchoscopy. While the client may experience some throat discomfort and hoarseness, restricting talking for such an extended period is unnecessary and may cause undue stress or anxiety for the client. Unless specifically instructed by the healthcare provider for a valid reason, such as to allow vocal cord healing, there is no need to restrict talking for such a long duration.

D. Suction the client's oropharynx frequently.

Frequent suctioning of the client's oropharynx is not indicated unless there is a specific medical reason to do so. Excessive suctioning can cause trauma to the mucous membranes, increase the risk of infection, and exacerbate throat irritation. The decision to suction should be based on clinical assessment, such as evidence of secretions or if the client is having difficulty clearing their airway, rather than being performed routinely.

A. Inspiratory stridor B. Nausea C. Retractions D. Muscle tremors E. Cyanosis

Correct Answer is ["A","C","E"]

Explanation

A. Inspiratory stridor

Inspiratory stridor is a high-pitched, musical sound heard during inspiration that indicates partial obstruction of the upper airway. It is a characteristic sign of airway obstruction and requires immediate attention.

B. Nausea

Nausea is not a common manifestation of airway obstruction. It may be associated with other conditions such as gastrointestinal issues or medication side effects but is not directly related to airway obstruction.

C. Retractions

Retractions refer to visible sinking of the skin between the ribs and above the clavicles during inspiration, which indicates increased effort to breathe. Retractions can occur in response to airway obstruction, as the body attempts to overcome the resistance to breathing.

D. Muscle tremors

Muscle tremors are not specific manifestations of airway obstruction. Tremors may occur due to various reasons such as anxiety, electrolyte imbalances, or neurological conditions but are not typically associated with airway obstruction.

E. Cyanosis

Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from inadequate oxygenation of the blood. It can occur with airway obstruction as oxygen exchange is compromised. Cyanosis is a late sign of respiratory distress and requires immediate intervention.

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A nurse is preparing to obtain a sputum specimen for a client. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has just had a bronchoscopy. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has an acute respiratory illness. For which of the following manifestations of an airway obstruction should the nurse monitor? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

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