A nurse is collecting a sputum specimen from a client who has tuberculosis.
Which of the following actions should the nurse take?
Obtain the specimen immediately upon the client waking up.
Ask the client to provide 15 to 20 mL of sputum into the container.
Wear sterile gloves to collect the specimen from the client.
Wait 1 day to collect the specimen if the client cannot provide sputum.
The Correct Answer is A
The correct answer is Choice a.
Choice a rationale: The nurse should obtain the specimen immediately upon the client waking up, as sputum from deep in the lungs is usually more easily collected at this time. Sputum collected upon waking up is more likely to contain secretions from the lower respiratory tract, providing a better sample for tuberculosis diagnosis. This timing maximizes the chance of detecting the bacteria.
Choice b rationale: Choice b is incorrect because the typical volume of sputum needed for testing is about 1 teaspoon (5 mL), not 15 to 20 mL. Collecting such a large volume could be challenging for the client and unnecessary for diagnostic purposes.
Choice c rationale: Choice c is incorrect because while gloves should be worn, they do not need to be sterile, just clean. The use of clean gloves is sufficient to prevent contamination during specimen collection, and sterile gloves are not required for this procedure.
Choice d rationale: Choice d is incorrect because it’s important to try to collect the specimen as soon as possible, not wait a full day. Delaying collection for a day could result in a missed opportunity to diagnose tuberculosis and initiate appropriate treatment promptly. Collecting the specimen promptly maximizes the accuracy of diagnostic testing and facilitates timely intervention for the client's health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Encouraging fluid intake of 2,500 mL/day is the correct choice for a client with a fever due to an infection. Adequate hydration is essential in managing fever as it helps to prevent dehydration, maintain electrolyte balance, and support the body's immune response. Increasing fluid intake, preferably water, can also aid in lowering body temperature and promoting overall comfort.
Choice B rationale:
Maintaining the environmental temperature at 16°C to 18°C (60°F to 65°F) is not an appropriate intervention for a client with a fever. While it's essential to keep the client comfortable, adjusting the room temperature within a specific range is not the primary intervention. Focus should be on managing the fever through hydration, antipyretic medications, and addressing the underlying infection.
Choice C rationale:
Immersing the client in cold water is not a recommended intervention for managing fever. Cold water immersion can lead to shock, vasoconstriction, and potentially worsen the condition. It is essential to use methods like tepid sponging or cooling blankets if necessary, but these interventions should be performed under healthcare provider guidance and monitoring.
Choice D rationale:
Assisting the client to ambulate is a general nursing care activity and does not specifically address the fever due to infection. While ambulation is encouraged for many patients to prevent complications related to immobility, it is not the primary intervention for managing fever. The focus should be on hydration and other appropriate measures to reduce fever.
Correct Answer is B
Explanation
Choice A rationale:
A client with obsessive-compulsive disorder being upset about a change in daily routine is concerning but does not present an immediate threat to their physical health or require urgent attention compared to a potential medical emergency like a sore throat.
Choice B rationale:
Clozapine, an atypical antipsychotic, can cause agranulocytosis, a potentially life-threatening condition characterized by a severe reduction in white blood cell count. Sore throat could be an early sign of this serious adverse effect. Therefore, a client taking clozapine reporting a sore throat requires immediate evaluation to rule out agranulocytosis, which can progress rapidly if not addressed promptly.
Choice C rationale:
A client with narcissistic personality disorder mocking others during group therapy is disruptive and inappropriate behavior but does not require immediate attention unless it escalates into a situation that threatens the safety of others or the therapeutic environment.
Choice D rationale:
A client with depressive disorder requiring assistance with activities of daily living (ADLs) needs support and care, but this does not indicate an urgent situation. While assistance with ADLs is important for the client's well-being, it is not a priority over a potential medical emergency like agranulocytosis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.