• A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse
... [Show More] take when collecting the specimen?
A. Instruct the client to defecate into the toilet bowl
-incorrect: The nurse should have the client defecate into a bedpan or a container for stool collection. The toilet water can dilute and contaminate the liquid specimen.
B. Transfer the specimen to a sterile container
-incorrect: The nurse should place the stool specimen in a clean container using a tongue depressor.
C. Refrigerate the collected specimen
-incorrect: The nurse should send the collected stool specimen immediately to the laboratory after labeling the specimen properly to prevent contamination with microorganisms and keep the specimen from getting cold.
D. Place the stool specimen collection container in a biohazard bag
-The nurse should place the specimen collection container in a biohazard bag with the client label on the container and the bag for easy identification. This will also prevent contamination with microorganisms.
-The nurse should confirm the NG tube placement by checking the X-ray results following the insertion of the NG tube. In addition, the nurse should check the length of the NG tube that is exposed by comparing the markings on the tube to the client’s nose to verify tube placement.
E. Check the aspirated fluid for glucose
-incorrect: Checking for glucose in the aspirated fluid is not a reliable method of determining correct NG tube placement.
• A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (SATA)
A. coat the tip of the tube with a water-soluble lubricant
B. Ask the client to swallow water while the tube enters her throat
-Lubricating the tube eases its passage. A water-based gel because it will dissolve if the tube slips into the client’s airway, while using petroleum jelly could cause respiratory problems. Swallowing water reduces the risk of gagging and aspiration and helps propel the tube down the esophagus. Hyperextending the neck reduces the curvature of the nasopharynx, which facilitates the insertion of the NG tube.
C. Place the coiled tube in ice chips prior to insertion
-incorrect: Ice makes NG tubes rigid, increasing the risk of trauma to mucous membranes.
D. Tell the client to tilt her head backward as insertion begins
-Lubricating the tube eases its passage. A water-based gel because it will dissolve if the tube slips into the client’s airway, while using petroleum jelly could cause respiratory problems. Swallowing water reduces the risk of gagging and aspiration and helps propel the tube down the esophagus. Hyperextending the neck reduces the curvature of the nasopharynx, which facilitates the insertion of the NG tube.
E. Instruct the client to bear down during insertion
-incorrect: Bearing down is helpful during the insertion of a urinary catheter, not an NG tube.
• A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take?
A. Hyper oxygenate the client before suctioning
-The nurse should use a manual resuscitation bag to hyper oxygenate the client for several minutes prior to suctioning.
B. Insert the catheter during exhalation
-incorrect: The nurse should insert the catheter during inhalation
C. Apply suction during insertion of the catheter
-incorrect: Applying suction while inserting the catheter increases the risk of damage to the tracheal mucosa and removes oxygen from the airways.
D. Apply suction for no more than 15 secs
-incorrect: The nurse should apply suction for no more than 10 seconds
• A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint?
A. Antigravity
-incorrect: The antigravity muscle group is responsible for stabilizing the knee joint.
B. Antagonistic
-The nurse should teach the client that the antagonistic muscle group is responsible for movement of the knee joint by contracting while other muscles relax.
C. Synergistic
-incorrect: The synergistic muscle group is responsible for contracting in sync to cause the same movement. Therefore, 2 muscles contract as other muscles relax. However, this is not occurring within a joint.
D. Skeletal
-incorrect: The skeletal muscle group is responsible for supporting posture and producing voluntary movement.
• A nurse is preparing to irrigate a client’s wound. Which of the following actions should the nurse take?
A. Use a 10 mL syringe
-incorrect: The nurse should use a syringe that has at least a 30 mL capacity.
B. Attach a 22-gauge catheter to the syringe
-incorrect: The nurse should use an 18- or 19-gauge catheter. A smaller catheter will exert too much pressure on the wound.
C. Warm the irrigating solution to 37 C (98.6 F)
-The nurse should prepare about 200 mL of irrigating solution and warm it to body temperature to minimize discomfort and vascular constriction.
D. Administer an analgesic 10 mins before the irrigation
-incorrect: The nurse should administer an analgesic 20 to 30 minutes before the irrigation to give the medication enough time to provide pain management during the procedure.
• A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client’s HIV infection status. Which of the following actions should the nurse take?
A. Inform the guard that the warden must request this information.
-incorrect: The nurse cannot discuss the client’s HIV status with the guard or the warden without the client’s consent. The client can share personal medical information if desired.
B. Ask the guard to sign a release of information form
-incorrect: The client can sign a release of information form to obtain medical records. Asking the guard to sign this form does not give the nurse permission to share the client’s HIV status. C. Instruct the guard to ask the inmate
-The nurse is not able to supply this information to the guard. In order for the guard to obtain this information, the client must offer the information freely. Therefore, the nurse should instruct the guard to ask the client for the information.
D. Complete an incident report
-incorrect: The nurse would have no cause to complete an incident report in this situation. Incident reports are completed to record an event that is not consistent with standard procedures. An incident report would need to be completed if the nurse were to share the client’s HIV status with the guard.
• A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning?
A. One week prior to the client’s discharge
-incorrect: Beginning to plan for the client’s discharge a week prior to the event might not allow sufficient time for planning. The nurse should begin discharge planning at the time of admission. B. Upon the client’s admission to the care facility
-The nurse should begin discharge planning at the time that the client is admitted to the facility.
C. Once the discharge date is identified
-incorrect: Beginning to plan for the client’s discharge once the discharge date is identified might not allow sufficient time for planning. The nurse should begin discharge planning at the time of admission.
D. When the client addresses the topic with the nurse
-incorrect: Beginning to plan for the client’s discharge once the discharge date is identified might not allow sufficient time for planning. The nurse should begin discharge planning at the time of admission. [Show Less]