A charge nurse overhears a newly licensed nurse providing instructions to a female client on the proper steps to collect a midstream urine specimen. Which of the following statements made by the newly licensed nurse requires the charge nurse to intervene?

"Use the provided towelette to cleanse the area by moving in a back-and-forth motion."

"Start the flow of urine before passing the container under the stream to collect the specimen."

"It will be easier to use your nondominant hand to spread the labia."

"Remove the specimen container before stopping the stream of urine”

Answer and Explanation

The Correct Answer is B

This statement is incorrect and requires correction because it suggests starting the flow of urine before positioning the collection container, which can result in contamination of the specimen. The correct procedure for collecting a midstream urine specimen involves the following steps:

1. Provide the client with a clean urine specimen container.

2. Instruct the client to cleanse the genital area using a provided towelette or antiseptic wipes, wiping from front to back.

3. Instruct the client to start urinating into the toilet or bedpan.

4. As the urine stream continues, the client should pass the collection container into the stream to collect the midstream specimen.

5. Once an adequate amount of urine has been collected (as per the laboratory's instructions), the client should remove the container from the stream of urine. 6. The client can then complete urinating into the toilet or bedpan.

The other statements made by the newly licensed nurse are correct:

"Use the provided towelette to cleanse the area by moving in a back-and-forth motion": This statement correctly instructs the client to cleanse the genital area before collecting the urine specimen.

"It will be easier to use your nondominant hand to spread the labia": This statement is correct as it suggests using the nondominant hand to facilitate the collection process.

"Remove the specimen container before stopping the stream of urine": This statement is correct as it indicates that the container should be removed before completing urination.

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Correct Answer is B

Explanation

Measuring the output from an indwelling urinary catheter is within the scope of practice for an assistive personnel (AP). It involves a straightforward task that does not require specialized nursing knowledge or judgment.

The other tasks mentioned should not be delegated to an AP:

Administer an enteral feeding to a client who has a new gastrostomy tube: Administering enteral feedings requires specialized knowledge and training to ensure proper placement and administration. This task should be performed by a licensed nurse.

Evaluate a client's pain level 30 min after receiving an oral analgesic: Evaluating pain level and the effectiveness of pain management requires nursing assessment and judgment. This task should be performed by a licensed nurse.

Reinforce foot care to a client who has a new diagnosis of diabetes mellitus: Providing education and reinforcing foot care to a client with a new diagnosis of diabetes requires

specialized knowledge about the disease and its management. This task should be performed by a licensed nurse.

Correct Answer is ["25"]

Explanation

To calculate the infusion rate in drops per minute (gtt/min), we can use the following formula: Infusion rate (gtt/min) = (Volume to be infused (ml) * Drop factor) / Time (min) Given:

Volume to be infused: 100 ml

Drop factor: 60 gtt/ml

Time: 4 hr

First, we need to convert the time from hours to minutes:

4 hr * 60 min/hr = 240 min

Now, we can calculate the infusion rate:

Infusion rate (gtt/min) = (100 ml * 60 gtt/ml) / 240 min

Simplifying the equation:

Infusion rate (gtt/min) = 6000 gtt / 240 min

Dividing both sides:

Infusion rate (gtt/min) ≈ 25 gtt/min

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A charge nurse overhears a newly licensed nurse providing instructions to a female client on the proper steps to collect a midstream urine specimen. Which of the following statements made by the newly licensed nurse requires the charge nurse to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse planning care for a group of clients is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

Correct Answer is B

Explanation

A nurse is preparing to administer 0.9% sodium chloride (NS) 100 mL IV to infuse over 4 hr. The drip factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number.)

Correct Answer is ["25"]

Explanation

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