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"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. “You may feel some cramping during the procedure.” - This response provides an honest and accurate expectation of potential discomfort during the colonoscopy.
B. “Don’t worry, you won’t remember anything about the procedure due to the effects of the medication.” - Sedation may help with recall, but it doesn't eliminate the possibility of feeling discomfort.
C. “Most clients report more discomfort from the preparation than from the procedure itself.” - While this statement is generally true, it doesn't directly address the client's concern about pain during the colonoscopy.
D. “You shouldn’t feel any pain since the local area is anesthetized.” - Colonoscopy is typically done with conscious sedation rather than local anesthesia, and some discomfort may still be felt.
Correct Answer is D
Explanation
a. Encourage the client to take small bites: While encouraging small bites is important, the priority for a client with dysphagia is to ensure they are in an upright position to prevent aspiration.
b. Place food in the unaffected side of the mouth: Placing food in the unaffected side of the mouth may not prevent aspiration and does not address the priority of positioning.
c. Offer mouth care before meals: While oral hygiene is important, it is not the priority when addressing the risk of aspiration during feeding.
d. Place the client in the upright position: The upright position helps prevent aspiration during swallowing, which is crucial for clients with dysphagia.
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