Which instructions should a nurse give to a client prior to obtaining a throat culture?
“While depressing your tongue, I will swab the back of your throat.”.
“You won’t be able to eat or drink for one hour after the procedure.”.
“Take a deep breath and then cough while I swab your throat.”.
“I just need to swab your anterior tongue. It will be very quick.”.
The Correct Answer is A
This is the proper way to obtain a throat culture, which is a test to look for infections in the back of the throat.
Some possible explanations for the other choices are:
Choice B is wrong because there is no need to avoid eating or drinking after a throat culture.
The swab does not interfere with the normal function of the mouth or throat.
Choice C is wrong because coughing while swabbing the throat could contaminate the sample or cause discomfort to the client. The swab should be gently passed along the back area of the throat and tonsils.
Choice D is wrong because swabbing only the anterior tongue would not collect enough cells from the infected area. The swab should reach the back of the throat where bacteria or fungi may grow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
It is a legal record of accountability for the protection of the client and the nurse. This means that documentation provides evidence of the assessments and interventions that have been undertaken by the nurse and can be used to defend the nurse in case of a lawsuit or a complaint. Documentation also supports the provision of safe, high-quality patient care by facilitating continuity of care and communication among health care providers.
Choice B is wrong because it is incomplete and misleading. Documentation supports confidentiality and privacy, but it should never be shared without the client’s consent or a legal authority.
Choice C is wrong because it is too narrow. Documentation provides continuous reference for all care providers to refer to, but it also has other purposes such as quality improvement, research, education and legal protection.
Choice D is wrong because it is inaccurate. Documentation does not provide a framework for clients rights, but rather reflects how the nurse respects and upholds those rights in practice. Documentation also records if clients rights are violated, but this is not the main rationale for documentation.
Correct Answer is A
Explanation
This is because the nurse should first ensure that help is on the way before performing any other actions on an unconscious and unresponsive client. Calling for assistance may also alert someone who can bring an automated external defibrillator (AED) if needed.
Choice B is wrong because giving 2 rescue breaths is part of CPR, which should only be done after checking for a pulse and finding none or a weak one.
Giving rescue breaths to a client who has a pulse may cause harm.
Choice C is wrong because checking for apical pulse is not the most reliable way to assess circulation in an emergency situation. The nurse should check for a carotid pulse instead, which is easier to locate and more indicative of blood flow to the brain.
Choice D is wrong because beginning chest compressions is also part of CPR, which should only be done after calling for assistance and checking for a pulse and finding none or a weak one.
Chest compressions may cause harm to a client who has a pulse.
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