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 A

Explanation

Choice A rationale:
Coughing and deep breathing are essential for mobilizing and removing secretions from the airways, which is crucial for improving airway clearance in patients with pneumonia. These techniques help to loosen mucus and bring it up from the lungs, allowing it to be expelled through coughing.
Hydration maintenance is also critical because it helps to thin secretions, making them easier to cough up. Adequate hydration helps to keep mucus moist and less sticky, which promotes easier expectoration.
Choice B rationale:
Keeping the head of the bed elevated can help to improve oxygenation and reduce the work of breathing, but it does not directly address the issue of airway clearance. It may be a helpful adjunct intervention, but it's not the priority for this specific nursing diagnosis.
Choice C rationale:
Preparation for insertion of a tracheostomy tube is a more invasive intervention that may be necessary in severe cases of airway obstruction, but it is not the first-line intervention for ineffective airway clearance related to pneumonia. It would be considered if other measures fail to maintain adequate ventilation.

Choice D rationale:
Providing supplemental oxygen can help to improve oxygenation in patients with pneumonia, but it does not directly address the issue of airway clearance. It's important to support oxygenation, but it's not the primary intervention to clear secretions.

A. Exercise B. Diet C. Sunlight D. Infection

Correct Answer is A

Explanation

The correct answer is A. Exercise.

Choice A: Exercise Exercise is generally beneficial for overall health and is not typically a factor that exacerbates systemic lupus erythematosus (SLE). In fact, regular physical activity can be an important part of the overall treatment plan for individuals with SLE. It can boost energy levels, improve joint flexibility, and help alleviate stress. Therefore, if a patient with SLE identifies exercise as a factor that can exacerbate their condition, it indicates a need for further teaching.

Choice B: Diet Certain diets can potentially trigger or worsen SLE symptoms. For instance, a chemical found in alfalfa may trigger lupus symptoms, so patients may want to avoid eating alfalfa sprouts or taking supplements with alfalfa. Therefore, diet is a correct factor that can exacerbate SLE.

Choice C: Sunlight Exposure to sunlight can trigger or worsen SLE symptoms. For those with lupus, being in the sun can lead to symptoms like skin rashes, itching, burning, joint pain, weakness, and fatigue. In certain cases, it can also result in damage to internal organs. Therefore, sunlight is a correct factor that can exacerbate SLE.

Choice D: Infection Infections can trigger or worsen SLE symptoms. Rates of infections are higher among persons with SLE compared with the general population. Therefore, infection is a correct factor that can exacerbate SLE.

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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

What intervention should the nurse identify as a priority for a client with a nursing diagnosis of ineffective airway clearance related to HIV related pneumonia?

Correct Answer is A

Explanation

A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE?

Correct Answer is A

Explanation

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)?

What intervention should the nurse identify as a priority for a client with a nursing diagnosis of ineffective airway clearance related to HIV-related pneumonia?

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