The practical nurse (PN) explains to a client how to obtain a sputum specimen and the client indicates understanding the procedure. After the PN leaves the room, the client obtains the specimen and notifies the PN. When the PN arrives to collect the specimen it appears as seen in the picture (in a non sterile basin with tissue paper). Which action should the PN take?
Place a biohazard bag over the basin and seal the bag securely for transport to the lab.
Assist the client in obtaining another specimen coughed directly into a sterile cup.
Use a wooden applicator to place the sputum specimen in a sterile container.
Apply gloves and place the tissue and specimen in a container for transport to the lab.
The Correct Answer is B
A. Placing a biohazard bag over the basin and sealing it is not appropriate because the specimen should have been collected directly into a sterile container, and the specimen's current state in a non-sterile basin is not acceptable for lab analysis.
B. Assisting the client in obtaining another specimen is necessary to avoid cross contamination.
C. Using a wooden applicator to place the sputum specimen in a sterile container is the incorrect as it breaches sterility.
D. Applying gloves and placing the tissue and specimen in a container is incorrect as the specimen must be in a sterile container from the start. Using a non-sterile basin means the specimen might be contaminated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Response 1
A. Fluid volume deficit
The client has signs of dehydration such as dry mucous membranes and a recent history of not having much to eat or drink in the past 2 days, which indicates a fluid volume deficit.
B. Respiratory alkalosis
There is no evidence to support respiratory alkalosis. The client's primary issues are related to infection and dehydration.
C. Hypoxia
The client’s oxygen saturation is 100% on 2 L/minute nasal cannula, so hypoxia is not a current issue.
D. Diarrhea
Diarrhea is not mentioned in the history, symptoms, or findings. It is not relevant to the client's condition.
Response 2
A. Decreased fluid intake
The client has not had much to eat or drink in the past 2 days, contributing directly to the fluid volume deficit.
B. Increased respiratory rate
While the client has an increased respiratory rate, it is a symptom of pneumonia rather than a cause of fluid volume deficit.
C. Infection
Although the client has pneumonia, the fluid volume deficit is more directly related to decreased fluid intake than to infection.
D. Heart disease
Heart disease is not mentioned and is not relevant to the client’s current presentation.
Correct Answer is D
Explanation
A. Skin turgor is important for assessing hydration status, but it is not the most critical factor when preparing for a safe transfer. For an unresponsive client, ensuring stable hemodynamic conditions is more urgent. Blood pressure provides essential information about the client’s circulatory status, which is crucial for assessing the risks associated with the transfer.
B. Body weight is generally used for dosing medications or assessing nutritional status and is not immediately relevant for ensuring a safe transfer of an unresponsive client. Although body weight might be useful in planning the transfer logistics, it does not impact immediate safety concerns.
C. Temperature can indicate infection or other issues but does not directly affect the immediate safety of the transfer process. While monitoring temperature is part of overall care, it is not the most pressing concern during the transfer.
D. Blood pressure is essential to check before the transfer because it reflects the client’s cardiovascular stability. Low or unstable blood pressure might increase the risk of complications during the transfer, such as a sudden drop in blood pressure that could lead to a fall or injury.
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