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 D
Explanation
Choice A rationale
The shoulder is not the correct fetal presentation in this case. The shoulder presentation, also known as a transverse lie, occurs when the fetus is positioned horizontally in the uterus, and the shoulder is the presenting part. This is not the case in an RSA (Right Sacrum Anterior) position, which indicates a breech presentation.
Choice B rationale
The vertex presentation, also known as a cephalic presentation, occurs when the fetus is positioned head down in the uterus. However, in an RSA position, the fetus is in a breech presentation, not a vertex presentation.
Choice C rationale
The mentum (face) presentation is a rare type of fetal presentation where the neck of the fetus is hyperextended, and the face presents at the cervix. This is not the case in an RSA position, which indicates a breech presentation.
Choice D rationale
In an RSA (Right Sacrum Anterior) position, the fetus is in a breech presentation. This means that the buttocks or feet of the fetus are positioned to enter the birth canal first. Therefore, the nurse should document a breech presentation in the patient’s medical record.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
While monitoring abdominal girth can be important in patients with cirrhosis, especially those with ascites, it is not typically an assessment finding that requires immediate follow-up.
Choice B rationale
A blood pressure of 82/58 mm Hg is low and could indicate hypotension, which requires immediate follow-up.
Choice C rationale
A heart rate of 101/min is elevated and could indicate tachycardia, which requires immediate follow-up.
Choice D rationale
An oxygen saturation of 92% is lower than the normal range of 95% to 100%, indicating potential hypoxia, which requires immediate follow-up.
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