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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because waiting for notification that the system has been rebooted can delay the client's care and compromise safety. The nurse should report the problem as soon as possible and use alternative methods of documentation.
Choice B Reason: This is incorrect because identifying information as late entry in the record is a secondary action that should be done after the system is restored. The nurse should prioritize resolving the technical issue and ensuring continuity of care.
Choice C Reason: This is correct because notifying information services department of the situation is the first action that the nurse should take to alert the experts who can troubleshoot and fix the problem. The nurse should also follow the facility's policy and procedure for documenting in a downtime situation.
Choice D Reason: This is incorrect because printing electronic medical record (EMR) from backup server may not be feasible or accessible depending on the extent of the system failure. The nurse should use paper forms or charts as a temporary measure until the system is back online.
Correct Answer is A
Explanation
Choice A: Reassess the client and the level of pain is the correct intervention because it helps the nurse evaluate the effectiveness of the medication and plan further actions. The nurse should use a valid and reliable pain scale and check for any signs of adverse effects or complications.
Choice B: Tell the client the medication needs more time to work is not a correct intervention because it may dismiss the client’s pain and delay appropriate treatment. The nurse should acknowledge the client’s pain and explain the expected onset and duration of the medication.
Choice C: Ask the UAP to offer a backrub to the client is not a correct intervention because it may not be sufficient or appropriate for the client’s pain. The nurse should assess the client’s pain before delegating any nonpharmacological interventions to the UAP.
Choice D: Encourage the client to focus on taking deep breaths is not a correct intervention because it may not be effective or feasible for the client’s pain. The nurse should assess the client’s pain and offer other complementary therapies that are suitable and acceptable for the client.
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