A nurse is preparing to obtain a sputum specimen for a client. Which of the following actions should the nurse plan to take?
Save the sputum specimen in a clean container.
Collect the sputum specimen after a meal.
Rinse the client's mouth before collecting the specimen.
Obtain the specimen from the client in the evening.
The Correct Answer is C
A. Saving the sputum specimen in a clean container.
While it is important to collect the sputum specimen in a clean, sterile container, simply saving the specimen in a clean container is not sufficient. The nurse needs to actively collect the sputum specimen from the client using proper technique to ensure that it is not contaminated and is suitable for laboratory analysis.
B. Collecting the sputum specimen after a meal.
Collecting a sputum specimen after a meal is not recommended, as it can increase the likelihood of contamination with food particles. It's preferable to collect the specimen before meals or at least 1-2 hours after eating to minimize the risk of contamination and ensure the integrity of the specimen.
C. Rinse the client's mouth before collecting the specimen.
When obtaining a sputum specimen from a client, it's important for the nurse to plan to rinse the client's mouth before collecting the specimen. Rinsing the mouth with water helps to clear any food particles or debris from the oral cavity, ensuring that the sputum sample collected is not contaminated with saliva or food particles. This improves the quality and accuracy of the specimen for laboratory analysis.
D. Obtaining the specimen from the client in the evening.
The timing of specimen collection is not necessarily restricted to the evening. The timing may vary depending on the client's condition and the healthcare provider's orders. It's important to follow the healthcare provider's instructions regarding the timing of specimen collection, which may be based on factors such as the client's symptoms and the diagnostic requirements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Air moves in and out of a wound in the chest wall.
In an open pneumothorax, also known as a sucking chest wound, there is a communication between the pleural space and the external environment through a wound in the chest wall. This allows air to move freely in and out of the pleural cavity during respiration. As a result, there is a loss of negative pressure within the pleural space, impairing lung expansion and leading to respiratory compromise. This condition is considered a medical emergency and requires prompt intervention to prevent tension pneumothorax and respiratory failure.
B. Air cannot pass freely into the thoracic cavity through a chest wound.
In an open pneumothorax, air can pass freely into the thoracic cavity through the chest wound. This communication between the external environment and the pleural space results in air movement in and out of the wound during respiration.
C. There are no audible sounds in an open pneumothorax.
In an open pneumothorax, there may be audible sounds, such as sucking or hissing sounds, particularly during inspiration. These sounds occur due to the movement of air in and out of the chest wound and can be indicative of the condition.
D. The air is trapped when it enters the cavity.
In an open pneumothorax, the air is not trapped when it enters the pleural cavity. Instead, air moves freely in and out of the wound in the chest wall, leading to respiratory compromise and potential progression to tension pneumothorax if left untreated.
Correct Answer is C
Explanation
A. Inspiratory stridor
Inspiratory stridor is a high-pitched, musical sound heard during inspiration and is typically caused by turbulent airflow due to partial obstruction of the upper airway. It is commonly associated with conditions such as croup, epiglottitis, or anaphylaxis. While respiratory distress may occur in a pneumothorax, inspiratory stridor specifically suggests an upper airway obstruction rather than a pneumothorax.
B. Expiratory wheeze
Expiratory wheeze is a high-pitched, musical sound heard during expiration and is typically associated with conditions such as asthma, chronic obstructive pulmonary disease (COPD), or bronchiolitis. Wheezing occurs due to narrowing of the airways, leading to turbulent airflow during expiration. While a pneumothorax can cause respiratory distress, it is not typically associated with wheezing.
C. Absence of breath sounds
The absence of breath sounds over a particular area of the chest can indicate a pneumothorax. In a pneumothorax, air accumulates in the pleural space, causing partial or complete collapse of the lung and preventing it from making contact with the chest wall. This absence of breath sounds over the affected area is a classic finding in a pneumothorax and is crucial for its detection.
D. Coarse crackles
Coarse crackles are discontinuous, bubbling or popping sounds heard during inspiration and may be indicative of conditions such as pneumonia, pulmonary edema, or bronchiectasis. These crackles are typically heard when there is fluid or mucus in the airways. While a pneumothorax can cause respiratory distress, it does not typically produce crackles on auscultation.
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