charge nurse overhears a newly licensed nurse providing instructions to a female client on the proper steps to collect a midstream urine specimen. Which of the following statements made by the newly licensed nurse requires the charge nurse to intervene?

"Use the provided towelette to cleanse the area by moving in a back-and-forth motion."

"It will be easier to use your nondominant hand to spread the labia."

"Start the flow of urine before passing the container under the stream to collect the specimen."

"Remove the specimen container before stopping the stream of urine"

Answer and Explanation

The Correct Answer is A

Choice A Rationale: The correct method for cleansing the area before collecting a midstream urine specimen is to wipe from front to back, not back-and-forth. This is to avoid contamination of the specimen with bacteria from the anal area. The towelette should be used in a single stroke and then discarded to ensure cleanliness.

Choice B Rationale: Using the nondominant hand to spread the labia is a standard practice that allows the dominant hand to manipulate the collection container. This technique helps to prevent contamination of the specimen by keeping the container away from the body and ensuring a clean catch.

Choice C Rationale: It is important to start the flow of urine before collecting the specimen to ensure that the 'midstream' urine is captured. This helps to flush out any bacteria that may be present at the opening of the urethra, reducing the risk of contaminating the sample.

Choice D Rationale: The specimen container should be removed from the stream before stopping the flow of urine to avoid contamination. The initial and final parts of the urine stream can carry bacteria from the urethra and skin, so only the midstream should be collected in the container.

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Correct Answer is B

Explanation

a. Asthma: While asthma can cause dyspnea and fatigue, it is not typically associated with tachycardia and edema.

b. Heart failure: Heart failure is characterized by symptoms such as dyspnea, fatigue,

tachycardia, and edema. Tachycardia may be a compensatory response to maintain cardiac output, and edema can result from fluid retention.

c. Aortic valve regurgitation: Aortic valve regurgitation may cause symptoms such as dyspnea and fatigue, but it is not typically associated with tachycardia and edema.

d. Aortic stenosis: Aortic stenosis may lead to symptoms such as dyspnea, but tachycardia and edema are not typical features of aortic stenosis.

A. Decrease the IV fluid infusion rate and limit oral fluid intake. B. Collect a urine specimen for culture and sensitivity. C. Continue routine care because the results are within the expected reference range. D. Evaluate urine output for amount and urine for specific gravity.

Correct Answer is D

Explanation

a. Decrease the IV fluid infusion rate and limit oral fluid intake: The client's BUN and creatinine levels are not significantly elevated, and limiting fluid intake may exacerbate dehydration.

Decreasing the IV fluid rate may not be indicated without further assessment.

b. Collect a urine specimen for culture and sensitivity: While obtaining a urine specimen is

important, the priority in this case is to evaluate the urine output for amount and specific gravity to assess renal function and fluid balance.

c. Continue routine care because the results are within the expected reference range: The elevated BUN, along with nausea and vomiting, suggests the need for further assessment rather than

continuing routine care without adjustments.

d. Evaluate urine output for amount and urine for specific gravity: This is the correct action to assess renal function and fluid balance. Monitoring urine output and specific gravity will help determine if the client's kidneys are effectively concentrating urine and adequately excreting waste products.

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charge nurse overhears a newly licensed nurse providing instructions to a female client on the proper steps to collect a midstream urine specimen. Which of the following statements made by the newly licensed nurse requires the charge nurse to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is collecting data from a client who reports dyspnea and fatigue.The nurse determines that the client also has tachycardia and edema. Which of the following disorders should the nurse suspect?

Correct Answer is B

Explanation

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. The client's BUN is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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