A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take?

Use sterile gloves to obtain the sputum specimen.

Place the sputum specimen in a clean container.

Collect the sputum specimen in the morning.

Obtain the sputum specimen after the client uses mouthwash.

Answer and Explanation

The Correct Answer is C

A.   Sterile gloves are not necessary for collecting sputum specimens. Clean gloves are typically sufficient.

B.   Sputum specimens should be collected in a sterile container to prevent contamination.
C.   Early morning specimens are preferred due to increased sputum production from the overnight accumulation of secretions.
D.   Mouthwash may contain substances that interfere with sputum culture results, so specimens should be collected before mouthwash use.

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Correct Answer is D

Explanation

A. With the Z-track method, the skin is pulled laterally or to the side before the needle is inserted and released after the injection is administered to ensure the medication remains within the muscle and does not leak into the subcutaneous tissue.
B. The angle of insertion for intramuscular injections can vary depending on factors such as the client's body habitus and the length of the needle but is typically 90 degrees.
C. The needle should be withdrawn slowly and steadily to minimize tissue trauma and prevent medication leakage.
D. The Z-track method involves pulling the skin laterally or to the side before inserting the needle to create a zigzag pathway for the medication. This helps seal the needle track after the injection, reducing the risk of medication leakage into subcutaneous tissues.

A. Instruct the client to take deep, rhythmic breaths. B. Encourage the client to apply a heating pad for 2 hr at a time. C. Remove distractions from the client's room. D. Apply an ice pack to the client's back for 1 hr.

Correct Answer is A

Explanation

A. Deep breathing is a relaxation technique that can help reduce pain by increasing oxygen delivery, decreasing muscle tension, and promoting a sense of calmness. The nurse should instruct the client to breathe slowly and deeply through the nose and exhale through the mouth.
B. Heat therapy may provide relief for muscle-related back pain but should not be applied for prolonged periods as it may cause tissue damage.
C. Minimizing environmental stimuli can help the client focus on relaxation techniques and alleviate pain perception but is not as effective as deep breathing.
D. Ice therapy is typically used for acute pain or inflammation and may not be appropriate for mild, ongoing back pain.

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A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering an intramuscular injection to a client using the Z-track method. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is planning to use nonpharmacological pain relief methods for a client who reports continued mild back pain after receiving analgesia 1 hr ago. Which of the following actions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is assessing a client who recently started taking an antibiotic. The nurse should identify that which of the following findings is an indication of a mild allergic reaction?

A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using wrist restraints, which of the following actions must the nurse take first?

A nurse is teaching a client about stress management techniques. Which of the following client statements indicates an understanding of the teaching?

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