A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Wipe the sample port with an alcohol wipe and let the alcohol dry.
Clamp the catheter tubing distal to the sampling port for 15 min.
Attach a sterile needleless syringe to the sample port and aspirate the specimen
Document in the client's electronic medical record that the specimen was sent to the laboratory.
Empty the urine into a sterile container labeled with the client identifiers
The Correct Answer is B, A, C, E, D
Clamp the catheter tubing distal to the sampling port for 15 min. By clamping the tubing distal to the sampling port, it allows urine to accumulate in the tubing, ensuring that the urine specimen obtained is fresh and not from the stagnant urine that has been sitting in the tubing.
Wipe the sample port with an alcohol wipe and let the alcohol dry. Cleaning the sampling port with an alcohol wipe helps reduce the risk of introducing contaminants into the sample during collection, ensuring a more sterile procedure.
Attach a sterile needleless syringe to the sample port and aspirate the specimen. Using a sterile syringe prevents contamination and allows for the collection of a clean urine sample directly from the catheter tubing, maintaining the sterility of the specimen.
Empty the urine into a sterile container labeled with the client identifiers. Transferring the collected urine into a sterile container labeled with the client's identifiers ensures proper identification and handling of the specimen for laboratory analysis.
Document in the client's electronic medical record that the specimen was sent to the laboratory. Documenting in the client's medical record ensures that there is a clear record of the specimen collection, its handling, and its dispatch to the laboratory for analysis, maintaining proper documentation and continuity of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Refill the prescription every 12 months. This statement focuses on the frequency of prescription refills rather than guidance on the medication's use. While it's important to keep prescriptions up to date, this instruction doesn't directly relate to the administration or use of sublingual nitroglycerin for angina.
Choice B Reason:
Take a second tablet after 5 minutes for unrelieved chest pain. This advice is crucial because if the chest pain persists after the first tablet, taking a second tablet after 5 minutes (and seeking emergency medical assistance if pain persists after the second tablet) is part of the recommended protocol for managing unstable angina with sublingual nitroglycerin.
Choice C Reason:
Swallow the tablet whole with a glass of water. Sublingual nitroglycerin is designed to dissolve under the tongue, not to be swallowed. The medicine is absorbed through the blood vessels in the mouth to provide rapid relief for angina symptoms. Instructing the patient to swallow the tablet defeats the purpose of sublingual administration.
Choice D Reason:
Store the medication in the refrigerator. Nitroglycerin should generally be stored in a cool, dry place and away from direct sunlight, but refrigeration is not necessary. Storing it in the refrigerator might actually alter the medication's effectiveness or consistency, making it less reliable for quick absorption when needed during an angina episode.
Correct Answer is C
Explanation
Choice A Reason:
Chill the dialysate prior to infusion. Generally, the dialysate used in peritoneal dialysis is warmed to body temperature before infusion to enhance comfort and prevent abdominal discomfort. Chilling the dialysate can cause discomfort and is not a standard practice in peritoneal dialysis.
Choice B Reason:
Monitor the client for diarrhea. While gastrointestinal symptoms might occur in some individuals undergoing peritoneal dialysis due to changes in fluid balance, diarrhea is not a typical or expected outcome. However, monitoring for any unusual gastrointestinal symptoms or changes in bowel habits is part of holistic client care.
Choice C Reason:
Weigh the client before and after the treatment. Weighing the client before and after peritoneal dialysis is a critical step to assess the effectiveness of the treatment. The difference in weight helps determine how much fluid was removed during the dialysis process, providing valuable information about the treatment's efficacy and the client's fluid status.
Choice D Reason:
Use clean gloves when handling dialysate bags. Maintaining aseptic technique during peritoneal dialysis is crucial to prevent infections. The use of clean gloves (not sterile gloves, unless otherwise specified) when handling dialysate bags helps minimize the risk of contamination, ensuring the safety of the procedure.
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