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
This is because the first priority for assessing an elderly client who has become confused since admission is to rule out hypoxia, which can cause or worsen delirium. Hypoxia can result from various conditions, such as pneumonia, pulmonary embolism, or heart failure.
Oxygen saturation measurement is a quick and non-invasive way to assess the oxygen level in the blood and identify hypoxia.
Choice B. Review of current medications is wrong because although medications can cause or contribute to confusion and delirium in older adults, they are not the most urgent assessment to perform.
Medications should be reviewed after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice C. Intake and output last 24 hours is wrong because although dehydration and electrolyte imbalance can cause or worsen confusion and delirium in older adults, they are not the most urgent assessment to perform.
Intake and output should be monitored after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice D. Use of hearing aids or glasses is wrong because although sensory impairment can cause or worsen confusion and delirium in older adults, it is not the most urgent assessment to perform.
The use of hearing aids or glasses should be ensured after ensuring adequate oxygenation and addressing other possible causes of confusion.
Normal ranges for oxygen saturation are 95% to 100% for healthy adults. Lower levels may indicate hypoxia or other respiratory or cardiac problems.
Correct Answer is C
Explanation
Tell me about it.” This response by the nurse would best facilitate communication because it acknowledges the client’s emotional state and invites the client to express their feelings.
It also shows empathy and respect for the client.
Choice A is wrong because it does not address the client’s emotional needs or encourage communication.
It also implies that the nurse is uncomfortable with the client’s crying and wants to avoid it. Choice B is wrong because it does not show empathy or support for the client.
It also indicates that the nurse is too busy or unwilling to listen to the client.
Choice D is wrong because it is too vague and does not acknowledge the client’s emotional state.
It also puts the burden on the client to come up with a solution for their problem.
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