A nurse is instructing a female client on how to collect a midstream urine sample. Which statement from the client indicates they understand the procedure?
I will clean the inside of the container with a wipe.
I will urinate a little then stop.
I will use each cleansing wipe twice.
I will use the cleansing wipe from front to back.
The Correct Answer is B
Choice A rationale
Cleaning the inside of the container with a wipe is not recommended. The container provided for a urine sample is sterile, and cleaning it could introduce bacteria, contaminating the sample.
Choice B rationale
The statement “I will urinate a little then stop” is correct. This is part of the process of collecting a midstream urine sample. The initial stream of urine can contain bacteria from the urethra or genital area, so it’s recommended to start urinating, then stop and collect the sample midstream.
Choice C rationale
The statement “I will use each cleansing wipe twice” is incorrect. Each cleansing wipe should only be used once to avoid reintroducing bacteria.
Choice D rationale
The statement “I will use the cleansing wipe from front to back” is correct. This is the proper way to clean the genital area to avoid introducing bacteria from the anal area into the urethra.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The patient’s blood pressure is significantly low, which could indicate hypotension, a serious side effect of epidural analgesia. This should be the nurse’s priority as it can lead to complications such as decreased perfusion to vital organs.
Choice B rationale
Lower extremity weakness can be a side effect of epidural analgesia, but it is not as immediately life-threatening as hypotension.
Choice C rationale
A slight increase in temperature may not be an immediate concern unless it continues to rise or is accompanied by other signs of infection.
Choice D rationale
Severe itching can be a side effect of epidural analgesia, but it is not as immediately life- threatening as hypotension.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
The nurse should first: C. Administer additional morphine for pain management, followed by B. Reposition the client for comfort.
The client is reporting a pain level of 6 on a scale from 0 to 10, which indicates moderate to severe pain. As per the medication administration record, the client has an order for Morphine 4 mg IV bolus every 6 hours PRN for pain. Since the client is in pain, it would be appropriate to administer the morphine first to manage the pain.
After addressing the client’s pain, the nurse should then reposition the client for comfort. This can help to alleviate any discomfort or pressure points that may be contributing to the client’s pain. It’s also important to ensure the client’s safety and comfort by making sure the call light is within reach.
The options related to restraints (A and D for Response 1, and A, B, C, D for Response 2) are not relevant in this scenario as there is no indication in the provided information that the client is being restrained or that restraints are necessary. The client is drowsy but arouses easily to verbal stimuli and is able to follow simple commands, suggesting that they are not at risk of harming themselves or others, which would necessitate the use of restraints. Therefore, these options can be ruled out.
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