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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. This is the correct answer. Reduction in blood pressure is a common therapeutic response to morphine administration. Morphine acts as a vasodilator, which can lead to decreased blood pressure.
B. Diaphoresis, or sweating, is not necessarily a therapeutic response to morphine. It may indicate other physiological responses or side effects.
C. Grimacing suggests pain or discomfort, which is not a therapeutic response but rather an indication that the pain relief from morphine may not be sufficient.
D. An elevated heart rate is not typically a therapeutic response to morphine and may indicate pain, anxiety, or other factors.

A. Increase in calf size B. Capillary refill of 2 seconds C. Palpable cord-like vein D. Extremity feels cool to the touch

Correct Answer is C

Explanation

A. An increase in calf size can be a sign of deep-vein thrombosis (DVT), but it is not specific to
DVT and can occur with other conditions such as edema.
B. Capillary refill of 2 seconds is within the expected range and is not indicative of DVT.
C. A palpable cord-like vein is a classic sign of DVT and should be further assessed and reported for appropriate intervention.
D. An extremity feeling cool to the touch can be a sign of impaired circulation but is not specific to DVT and can occur with other vascular conditions.

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A nurse is collecting a sputum specimen from a client for culture and sensitivity. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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