A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take?
Wear sterile gloves to collect the specimen from the client.
Obtain the specimen immediately upon the client waking up.
Wait 1 day to collect the specimen if the client cannot provide sputum.
Ask the client to provide 15 to 20 mL of sputum into the container.
The Correct Answer is B
A. Clean gloves (not sterile) are sufficient for collecting a sputum sample.
B. The best time to collect a sputum specimen is immediately upon waking because secretions accumulate overnight, making it easier to obtain a sample.
C. Waiting a day delays diagnosis and treatment; other techniques can help induce sputum production.
D. Typically, 5 to 10 mL of sputum is sufficient for diagnostic testing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E","F"]
Explanation
A. Exert upward pressure on the presenting part. If there are signs of cord prolapse or pressure on the umbilical cord, exerting upward pressure on the presenting part can relieve compression. This action helps maintain blood flow and oxygen supply to the fetus.
B. Place the client in a Trendelenburg position. Positioning the client with the pelvis elevated higher than the head can reduce pressure on the umbilical cord if prolapse is suspected or confirmed. This promotes fetal circulation and decreases the risk of hypoxia.
C. Administer oxygen at 10 L/min via nonrebreather face mask. Administering high-flow oxygen increases maternal oxygenation, which in turn improves oxygen delivery to the fetus. This is a priority intervention to ensure fetal well-being during labor.
D. Attempt to push the umbilical cord back into the cervix. This is incorrect because pushing the cord back into the cervix is contraindicated due to the risk of damaging the cord or introducing infection. Other measures, such as repositioning and elevating the presenting part, should be prioritized instead.
E. Have the charge nurse notify the provider. Timely communication with the provider is critical when complications arise during labor, such as suspected umbilical cord prolapse. The provider may need to intervene urgently, possibly requiring an emergency cesarean section.
F. Increase the flow rate of the maintenance IV fluid. Increasing the IV fluid rate helps improve maternal circulation and blood flow to the uterus and placenta, ensuring the fetus receives adequate oxygen and nutrients. This is a supportive measure during labor when complications arise.
Correct Answer is D
Explanation
A. Monitoring every 30 minutes is insufficient; it should be more frequent.
B. Providers must evaluate the client within 1 hour of restraint initiation, not 36 hours.
C. Restraint prescriptions for adults must be renewed every 4 hours, not 6.
D. Documenting the client’s behavior every 15 minutes ensures continuous assessment and compliance with safety protocols.
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