A nurse is collecting a sputum specimen from a client for culture and sensitivity. Which of the following actions should the nurse take?
Collect 2 mL of sputum in an emesis basin.
Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection.
Swab the oropharynx with a sterile swab.
Refrigerate the specimen until the time of transport to the laboratory.
The Correct Answer is D
A: Collecting 2 mL of sputum in an emesis basin is not the standard practice as it may not be sterile and could contaminate the specimen.
B: Instructing the client to rinse with an antiseptic mouthwash prior to specimen collection could potentially kill bacteria that need to be cultured, leading to an inaccurate test result.
C: Swabbing the oropharynx with a sterile swab is not the correct method for collecting a sputum specimen for culture and sensitivity, as this method is more suitable for throat cultures.
D: Refrigerating the specimen until the time of transport to the laboratory is the correct action because it preserves the integrity of the sputum sample by slowing down bacterial growth, ensuring that the culture and sensitivity results are accurate. Refrigeration is essential to prevent overgrowth of commensal bacteria that may be present in the specimen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This response respects the client's autonomy and right to make decisions about their own healthcare. It acknowledges the client's right to refuse treatment, even if it is recommended by healthcare providers.
B. While it is important to communicate the client's wishes to the healthcare provider, the nurse should not threaten to report the client's decision without their consent. This could undermine trust between the nurse and the client.
C. While it is true that refusing treatment may have medical consequences, this statement may come across as judgmental or coercive. The nurse should provide information about the potential consequences of refusing treatment in a supportive and non-coercive manner.
D. Suggesting that the client consult with a clergyperson before making a treatment decision is not necessarily relevant to the client's medical decision-making process. It may also imply that the decision should be based on religious beliefs rather than personal values and preferences.
Correct Answer is D
Explanation
A. Tachycardia is not typically associated with opioid intoxication. Instead, bradycardia or normal heart rate may occur due to the depressant effects of opioids on the central nervous system.
B. Opioid intoxication often results in decreased mental alertness, leading to symptoms such as drowsiness, confusion, or even unconsciousness.
C. Hyperreflexia, or exaggerated reflexes, is not a common manifestation of opioid intoxication. Instead, hyporeflexia or depressed reflexes may occur due to the central nervous system depression caused by opioids.
D. Pinpoint pupils are a classic sign of opioid intoxication. Opioids bind to receptors in the brainstem, causing pupillary constriction. This effect is so characteristic that pinpoint pupils are often referred to as "opioid pupils."
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