A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take?
Wear sterile gloves when collecting the sample.
Discard samples that contain urine.
Collect three samples from a single bowel movement.
Take the sample from the outer edge of formed stool.
The Correct Answer is B
Choice A reason: While wearing gloves is a standard precaution to prevent contamination and protect the nurse from potential pathogens, the gloves used for collecting a guaiac smear sample do not need to be sterile. Clean, non-sterile gloves are typically sufficient for this procedure.
Choice B reason: It is crucial to discard any samples that contain urine because urine can interfere with the results of the fecal occult blood test (FOBT). The presence of urine can cause false positives due to the peroxidase activity in urine, which can lead to unnecessary further testing.
Choice C reason: Collecting three samples from a single bowel movement is not recommended. Instead, it is advised to collect samples from three separate bowel movements to increase the likelihood of detecting intermittent bleeding, which is common in conditions like colorectal cancer.
Choice D reason: Taking the sample from the outer edge of formed stool is not the best practice. The sample should be taken from different areas of the stool to ensure a representative sample, as blood may not be uniformly distributed throughout the stool.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Ocular irrigation should be performed from the inner corner (near the nose) toward the outer corner to avoid contaminating the other eye and to ensure that the flushing fluid and any chemical residue flow away from the unaffected eye. This method helps to minimize the risk of spreading the chemical to the other eye and allows for a more effective removal of the chemical from the affected eye.
Choice B reason: While positioning the client upright is correct, having the head turned toward the right side is not specifically recommended. The client should be positioned in a way that facilitates the flow of the irrigation fluid away from the unaffected eye, which typically means tilting the head to the side of the affected eye.
Choice C reason: Placing a strip of pH paper under the upper lid of the affected eye is done to measure the pH of the tear film and determine the acidity or alkalinity of the chemical involved. However, this is not an immediate action during the initial irrigation process. The first priority is to dilute and remove the chemical from the eye as quickly as possible.
Choice D reason: While sterile water can be used for ocular irrigation, it is not the first choice. The preferred solution for ocular irrigation is a saline solution or specific eye irrigating solutions because they are isotonic and less irritating to the eye tissues. Sterile water may cause discomfort due to its hypotonicity, which can lead to cellular swelling.
Correct Answer is B
Explanation
Choice A reason: Telling a family to limit discussing past events with the client may not be culturally sensitive. Each culture has its own views on reminiscing and sharing memories, especially during end-of-life care. Some cultures value the sharing of stories and memories as a way to honor the individual's life.
Choice B reason: Saying "We will respect what is important to you" is a statement that acknowledges and incorporates the client's and family's cultural beliefs. It shows a willingness to understand and prioritize their values, customs, and preferences in the care plan. This approach is aligned with culturally competent care, which is crucial in hospice settings.
Choice C reason: Offering to arrange all burial services may overstep boundaries, as burial practices are deeply rooted in cultural and religious beliefs. It is important for healthcare providers to discuss and understand the family's wishes and provide support in accordance with their specific cultural practices.
Choice D reason: Advising that grieving should not be done in front of the client may not align with the family's cultural beliefs about expressing emotions and grief. Different cultures have varied expressions of grief, and it is essential to respect these practices. Some cultures view the open expression of grief as an important part of the mourning process.

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