A nurse is delegating collection of a random stool specimen to an unlicensed assistive personnel (UAP). Which information should the nurse provide?

Place chlorhexidine in the client's commode before they provide the sample.

Double-bag the specimen if it must be placed in a refrigerator containing medication.

Collect pus from the stool with a sterile swab and place it in a sterile test tube.

Wrap the tongue blades used to retrieve the specimen in a paper towel before disposal.

Answer and Explanation

The Correct Answer is D

A random stool specimen is a non-invasive diagnostic procedure used to detect pathogens, occult blood, or fecal fat content. Proper collection technique prevents contamination from urine or external chemicals, ensuring the diagnostic validity of the laboratory analysis. The nurse must provide clear instructions on the use of personal protective equipment and the safe disposal of biohazardous materials to prevent nosocomial transmission.

Rationale:

A. The introduction of chemical agents like chlorhexidine into the collection container is contraindicated because it alters the specimen’s composition. Disinfectants can kill the very microorganisms the laboratory is attempting to culture, leading to false-negative results. The commode should be clean and dry, free from all detergents or antiseptic solutions.

B. Specimens should never be stored in a refrigerator that contains medication or food due to the risk of cross-contamination. Facility protocols require a dedicated, labeled biohazard refrigerator for the temporary storage of laboratory samples. Proper placement ensures that pharmaceutical integrity is maintained while following strict infection control guidelines.

C. Collecting specific components like pus with a sterile swab is an advanced technique typically reserved for culture and sensitivity testing. For a random stool specimen, the UAP should collect a representative sample of the stool itself rather than focusing on exudates. Advanced specimen retrieval often requires licensed nursing judgment to ensure proper sampling.

D. Used tongue blades are considered contaminated waste and must be handled to prevent the spread of enteric pathogens. Wrapping them in a paper towel before placing them in the biohazard receptacle reduces the risk of accidental contact for environmental services staff. This practice maintains a clean environment and adheres to standard precautions for fecal matter.

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Correct Answer is ["A","C"]

Explanation

Aspiration occurs when gastric contents or oropharyngeal secretions enter the larynx and lower respiratory tract. It results from impaired deglutition or protective airway reflexes, leading to chemical pneumonitis or bacterial pneumonia. Specific nursing interventions prioritize maintaining a protected airway by modifying bolus consistency and enhancing the swallowing reflex through physical stimulation.

Rationale:

A. Altering the texture of solid medications to a bolus consistency improves swallow control. Mixing crushed medication with thickened agents like applesauce prevents the fragmentation of particles in the pharynx. This reduces the risk of silent aspiration in patients with oropharyngeal dysphagia or delayed swallow initiation.

B. Hyperextending the neck is strictly contraindicated as it opens the airway and inhibits effective epiglottic closure. Safe swallowing requires the chin-tuck maneuver to narrow the laryngeal inlet and widen the vallecular space. Proper positioning is the most critical factor in preventing pulmonary aspiration during oral intake.

C. Gentle upward stroking of the submental muscles encourages laryngeal elevation and facilitates the pharyngeal phase of swallowing. This physical cue helps initiate the reflexive movement required to seal the glottis during the passage of a bolus. It is a recognized technique for patients with sensory deficits.

D. Excessive fluid administration increases the risk of thin liquids entering the trachea before the swallow reflex triggers. Thin water is the most difficult consistency for dysphagic patients to manage safely without coughing. Fluids should be thickened according to speech therapy recommendations rather than given freely during meds.

E. Using a straw often delivers a large volume of fluid to the posterior pharynx too quickly for the patient to control. Straw use bypasses the oral preparatory phase, significantly increasing the likelihood of penetration into the airway. Patients with swallowing difficulties should sip directly from a cup to regulate bolus size.

A. The client with pheochromocytoma who has a severe pounding headache and chest pain. B. The client with the syndrome of inappropriate antidiuretic hormone has decreased urine output. C. The client with acromegaly who has club-like fingertips and large feet. D. The client with Cushing's syndrome who has truncal obesity and thin, fragile skin.

Correct Answer is A

Explanation

Endocrine emergencies such as pheochromocytoma crisis, SIADH-related fluid imbalance, and Cushing syndrome complications require rapid prioritization based on risk of hemodynamic instability, neurologic compromise, and organ perfusion failure. Pheochromocytoma causes excessive catecholamine secretion leading to severe hypertensive crises and acute cardiovascular events.

Rationale:

A. Severe pounding headache and chest pain in pheochromocytoma suggest catecholamine surge crisis with risk of hypertensive emergency, myocardial infarction, or stroke. This is life-threatening and requires immediate assessment and intervention to prevent cardiovascular collapse.

B. SIADH with decreased urine output reflects water retention and dilutional hyponatremia, but it is generally less immediately life-threatening than acute catecholamine crisis. Neurologic symptoms would increase urgency, but none are described here.

C. Acromegaly is a chronic condition caused by excess growth hormone secretion, leading to gradual somatic changes such as enlarged extremities. It is not an acute emergency and does not require immediate intervention.

D. Cushing syndrome presents with chronic hypercortisolism, causing truncal obesity and fragile skin. While it increases infection and metabolic risk, it is a long-term condition and not an immediate priority compared to acute hypertensive crisis.

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A nurse is delegating collection of a random stool specimen to an unlicensed assistive personnel (UAP). Which information should the nurse provide?

Nursing Test Bank

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