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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:
Providing a urine sample to determine therapeutic levels of phenytoin is not typically a part of routine discharge instructions. While monitoring of phenytoin levels is important, it's usually done through blood tests, and the frequency of testing is determined by the healthcare provider based on individual patient factors.

Choice C rationale:
Bleeding gums are not a common side effect of phenytoin. While some individuals might experience gum tenderness or overgrowth, significant bleeding is not expected.

Choice D rationale:
Antacids can actually interfere with the absorption of phenytoin, potentially reducing its effectiveness. Therefore, it's generally not recommended to take antacids regularly while on phenytoin therapy. If a patient needs to take an antacid for occasional heartburn or indigestion, it's best to take it at least 2 hours before or after the phenytoin dose.

A. “Were you feeling jittery or irritable prior to the seizure?” B. “Are you feeling sleepy or very tired at this time?” C. “When did you last take your seizure medication?” D. “Do you know if you lost consciousness during the seizure?”

Correct Answer is C

Explanation

Choice A rationale:
While inquiring about pre-seizure symptoms can be informative, it's not the most crucial question at this point. The priority is to gather information about medication adherence to assess potential causes for the breakthrough seizure.

Choice B rationale:
Assessing for post-ictal fatigue is important, but it's not the most pressing question in the immediate aftermath of a seizure. Determining medication adherence takes precedence.

Choice D rationale:
Establishing whether consciousness was lost can aid in classifying seizure type, but it's not as critical as understanding medication adherence in the initial assessment.

Choice C rationale:
This question directly addresses a potential cause of the seizure. Understanding when the client last took their medication can help determine if missed or delayed doses contributed to the seizure, guide medication adjustments, and inform further seizure prevention strategies.

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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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing discharge instructions to a patient who has a prescription for phenytoin. Which of the following information should the nurse include?

Correct Answer is B

Explanation

A client with a history of seizures is being admitted to the emergency room after experiencing a partial seizure. Which question would be most appropriate for the nurse to ask the client?

Correct Answer is C

Explanation

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