While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown.
Which action should the nurse implement?

Wait to obtain the specimen until observable blood is present.

Withhold specimen collection until tarry black stool is observed.

Obtain the specimen from the client's current bowel movement.

Contact the healthcare provider before obtaining the specimen.

Answer and Explanation

The Correct Answer is C

Choice A Reason: This is incorrect because occult blood is not visible to the naked eye. Waiting for observable blood may delay diagnosis and treatment of gastrointestinal bleeding.

Choice B Reason: This is incorrect because tarry black stool indicates upper gastrointestinal bleeding, which may not be related to the client's condition. Occult blood can be present in any color of stool.

Choice C Reason: This is correct because the nurse should obtain the specimen from the client's current bowel movement, regardless of its color or consistency. The test for occult blood detects hemoglobin in the stool, which may indicate bleeding anywhere along the gastrointestinal tract.

Choice D Reason: This is incorrect because contacting the healthcare provider before obtaining the specimen is unnecessary and may waste time. The nurse should follow the protocol for stool specimen collection and report any abnormal findings to the provider.

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Correct Answer is C

Explanation

Choice A: Blood pressure is not the first vital sign to obtain because it is not as sensitive to changes in the level of consciousness as respiratory rate. Blood pressure may be normal or elevated in some cases of decreased consciousness, such as stroke or head injury.

Choice B: Temperature is not the first vital sign to obtain because it is not as relevant to the level of consciousness as respiratory rate. Temperature may be normal or slightly elevated in some cases of decreased consciousness, such as infection or dehydration.

Choice C: Respiratory rate is the first vital sign to obtain because it reflects the adequacy of oxygenation and ventilation, which are essential for brain function. Respiratory rate may be increased, decreased, or irregular in cases of decreased consciousness, depending on the cause and severity.

Choice D: Pulse rate is not the first vital sign to obtain because it is not as indicative of the level of consciousness as respiratory rate. Pulse rate may be normal, fast, or slow in cases of decreased consciousness, depending on the cause and compensatory mechanisms.

A. Removes needle before discarding used syringes. B. Wears gloves to dispose of the needle and syringe. C. Washes hands before handling the needle and syringe. D. Dons a face mask before administering the medication.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because removing needle before discarding used syringes may expose the client or others to accidental needlestick injuries. The needle and syringe should be disposed of as a single unit in a puncture-resistant container.

Choice B Reason: This is incorrect because wearing gloves to dispose of the needle and syringe is not necessary if the client does not have contact with blood or body fluids. Gloves are not a substitute for hand hygiene.

Choice C Reason: This is correct because washing hands before handling the needle and syringe reduces the risk of infection and contamination. Hand hygiene is the most important measure to prevent transmission of microorganisms.

Choice D Reason: This is incorrect because donning a face mask before administering the medication is not required unless the medication is aerosolized or nebulized. A face mask does not protect against needlestick injuries or bloodborne pathogens.

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While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown.
Which action should the nurse implement?