A nurse on a medical-surgical unit is providing care for a group of clients. Which of the following specimens should the nurse delegate collection of to the assistive personnel (AP)?
Urine from an indwelling catheter
Blood for PaCO2
Wound drainage for culture
Random stool specimen
Random stool specimen
The Correct Answer is D
Choice A rationale:
Urine collection from an indwelling catheter is a sterile procedure that requires aseptic technique to prevent contamination of the specimen and potential urinary tract infection. Assistive personnel (AP) may not have the necessary training in sterile technique and therefore should not be delegated this task. Additionally, the nurse needs to assess the patient for any signs of urinary tract infection or other complications before collecting the urine specimen, which is within the scope of nursing practice.
Choice B rationale:
Blood collection for PaCO2 (partial pressure of carbon dioxide) is an invasive procedure that requires assessment of the patient's condition, appropriate site selection, and proper technique to ensure accurate results. This task is within the scope of nursing practice and should not be delegated to AP.
Choice C rationale:
Wound drainage collection for culture also requires aseptic technique to prevent contamination of the specimen and ensure accurate results. The nurse needs to assess the wound for signs of infection, choose the appropriate collection method, and ensure proper labeling and transport of the specimen. This task is within the scope of nursing practice and should not be delegated to AP.
Choice D rationale:
Random stool specimen collection is a non-invasive procedure that does not require sterile technique. AP can be trained to collect random stool specimens safely and effectively, following standard precautions for handling body fluids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Delivering meal trays to clients in their rooms is a simple task that does not require any specialized skills or knowledge. Volunteers can be safely assigned this task, as it does not involve any direct patient care or decision-making.
Choice B rationale:
Observing postoperative clients who are confused requires a higher level of skill and knowledge than delivering meal trays. Volunteers are not typically trained to assess and monitor patients for changes in their condition, and they may not be able to recognize and respond to potential emergencies. This task is best assigned to a licensed nurse or other qualified healthcare professional.
Choice C rationale:
Assisting ambulatory clients with meals is another task that can be safely assigned to volunteers. This task involves helping patients with simple activities such as opening food containers and cutting food. Volunteers can be trained to perform these tasks safely and effectively.
Choice D rationale:
Delivering mail is a simple task that does not require any specialized skills or knowledge. Volunteers can be safely assigned this task, as it does not involve any direct patient care or decision-making.
Correct Answer is A
Explanation
Choice A rationale:
Protecting the airway is the highest priority during a tonic-clonic seizure. Tonic-clonic seizures involve intense muscle contractions, which can lead to biting the tongue, aspiration of secretions, or even respiratory arrest if the airway is obstructed. Turning the client's head to the side helps to maintain a clear airway and prevent these complications.
It is essential to act quickly to prevent injury and ensure adequate oxygenation. Delaying airway management could have serious consequences.
Choice B rationale:
Checking motor strength is not a priority during the active phase of a seizure. It is more important to focus on protecting the airway and preventing injury.
Motor strength can be assessed after the seizure has subsided.
Choice C rationale:
Loosening clothing around the waist may be helpful to promote comfort and breathing, but it is not the first priority. It is more important to address the airway and prevent aspiration.
Choice D rationale:
Documenting the time the seizure began is important for accurate record-keeping and assessment of seizure patterns, but it is not the first priority in the immediate management of the seizure. Documentation can be done after the client's airway and safety are ensured.
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