A nurse on a medical-surgical unit is providing care for a group of clients. Which of the following specimens should the nurse delegate collection of to the assistive personnel (AP)?
Urine from an indwelling catheter
Blood for PaCO2
Wound drainage for culture
Random stool specimen
Random stool specimen
The Correct Answer is D
Choice A rationale:
Urine collection from an indwelling catheter is a sterile procedure that requires aseptic technique to prevent contamination of the specimen and potential urinary tract infection. Assistive personnel (AP) may not have the necessary training in sterile technique and therefore should not be delegated this task. Additionally, the nurse needs to assess the patient for any signs of urinary tract infection or other complications before collecting the urine specimen, which is within the scope of nursing practice.
Choice B rationale:
Blood collection for PaCO2 (partial pressure of carbon dioxide) is an invasive procedure that requires assessment of the patient's condition, appropriate site selection, and proper technique to ensure accurate results. This task is within the scope of nursing practice and should not be delegated to AP.
Choice C rationale:
Wound drainage collection for culture also requires aseptic technique to prevent contamination of the specimen and ensure accurate results. The nurse needs to assess the wound for signs of infection, choose the appropriate collection method, and ensure proper labeling and transport of the specimen. This task is within the scope of nursing practice and should not be delegated to AP.
Choice D rationale:
Random stool specimen collection is a non-invasive procedure that does not require sterile technique. AP can be trained to collect random stool specimens safely and effectively, following standard precautions for handling body fluids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Flu-like symptoms: These are common during the early stages of HIV infection, often within 2-4 weeks after exposure to the virus. They are a result of the body's immune system responding to the virus. Symptoms can include:
Fever Fatigue
Muscle aches
Headache Sore throat
Rash
Swollen lymph nodes
Night sweats: These are also common in early HIV infection and can be caused by the body's attempts to fight off the virus or by inflammation. They can also be a side effect of some HIV medications.
Choice B rationale:
Kaposi's sarcoma (KS): This is a type of cancer that is associated with HIV infection. It is caused by a virus called Kaposi's sarcoma-associated herpesvirus (KSHV). KS often appears as purple or red lesions on the skin or in the mouth. It can also affect other organs, such as the lungs and lymph nodes. However, it's not a common initial symptom of HIV infection. It usually develops in later stages of HIV when the immune system is severely weakened.
Choice C rationale:
Fungal and bacterial infections: People with HIV are more susceptible to infections because the virus weakens their immune system. However, fungal and bacterial infections are not typically among the initial symptoms of HIV infection. They usually occur in later stages of the disease when the immune system is more compromised.
Choice D rationale:
Pneumocystis lung infection (PCP): This is a serious lung infection that is caused by a fungus called Pneumocystis jirovecii. It is a common opportunistic infection in people with HIV, but it is not typically an initial symptom. It usually develops in later stages of HIV when the CD4 count (a measure of immune system health) is very low.
Correct Answer is ["1370"]
Explanation
To calculate the total output for the client, we need to add up all the individual outputs:
- The client voided 400 mL at 1100.
- The client voided 350 mL at 1430.
- The closed chest drainage system increased from 155 mL to 175 mL, which is an increase of 20 mL.
- The NG tube has 575 mL in the drainage container.
- The Jackson-Pratt drainage tube has 25 mL.
Adding all these amounts together, the total output that the nurse should record in the medical record is 1370 mL.
Here’s the calculation:
400 mL + 350 mL + (175 mL - 155 mL) + 575 mL + 25 mL = 1370 mL400mL+350mL+(175mL−155mL)+575mL+25mL=1370mL
So, the nurse should record a total output of 1370 mL in the medical record for the client.
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