The practical nurse (PN) explains to a client how to obtain a sputum specimen and the client indicates understanding the procedure. After the PN leaves the room, the client obtains the specimen and notifies the PN. When the PN arrives to collect the specimen it appears as seen in the picture (in a non sterile basin with tissue paper). Which action should the PN take?
Place a biohazard bag over the basin and seal the bag securely for transport to the lab.
Assist the client in obtaining another specimen coughed directly into a sterile cup.
Use a wooden applicator to place the sputum specimen in a sterile container.
Apply gloves and place the tissue and specimen in a container for transport to the lab.
The Correct Answer is B
A. Placing a biohazard bag over the basin and sealing it is not appropriate because the specimen should have been collected directly into a sterile container, and the specimen's current state in a non-sterile basin is not acceptable for lab analysis.
B. Assisting the client in obtaining another specimen is necessary to avoid cross contamination.
C. Using a wooden applicator to place the sputum specimen in a sterile container is the incorrect as it breaches sterility.
D. Applying gloves and placing the tissue and specimen in a container is incorrect as the specimen must be in a sterile container from the start. Using a non-sterile basin means the specimen might be contaminated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Heart rate 99 beats/minute
A heart rate of 99 beats/minute is slightly elevated. Tachycardia can be a sign of fluid volume deficit, as the body compensates for decreased blood volume and pressure by increasing heart rate to maintain adequate perfusion.
B. Dark, yellow urine
Dark yellow urine indicates concentrated urine, which is a sign of dehydration or fluid volume deficit. Proper hydration would typically result in light yellow urine.
C. Urinated 30 mL
A urine output of 30 mL is low, especially for an adult in a 1-hour period. Low urine output can be a sign of fluid volume deficit, as the kidneys may not be excreting enough urine due to inadequate fluid intake or retention.
D. Temperature 101° F (38.3° C)
An elevated temperature indicates a fever, which is related to the infection (pneumonia) rather than fluid volume status. It does not directly indicate a fluid volume deficit.
E. Client is awake and alert
Being awake and alert indicates that the client’s neurological status is stable and is not indicative of fluid volume deficit. It does not reflect the client’s fluid volume status.
F. Blood pressure 115/71 mm Hg
A blood pressure of 115/71 mm Hg is within normal limits. While fluid volume deficits can affect blood pressure, this finding alone does not indicate a deficit since the blood pressure is stable.
Correct Answer is D
Explanation
A. Measles Mumps Rubella (MMR) vaccine is typically administered at 12-15 months of age, not at 2 months. It is part of the recommended immunization schedule but is not given during the 2-month visit.
B. Varicella vaccine is usually given at 12-15 months of age. It is essential for preventing chickenpox but is not included in the 2-month immunization schedule.
C. Hepatitis A vaccine is recommended starting at 12 months of age. It is not part of the immunizations administered at 2 months.
D. Hepatitis B vaccine is part of the routine immunization schedule for infants and is given at birth, 1-2 months, and 6-18 months. At the 2-month visit, it is appropriate to administer the second dose of the Hepatitis B vaccine if it was not given at 1 month.
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