Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. "Use the provided towelette to cleanse the area by moving in a back-and-forth motion."
"Use the provided towelette to cleanse the area by moving in a back-and-forth motion." - This is a correct instruction for cleaning the genital area before collecting a midstream urinespecimen.
B. "It will be easier to use your nondominant hand to spread the labia."
"It will be easier to use your nondominant hand to spread the labia." - This is a correct instruction to facilitate the collection of a midstream urine specimen.
C. "Start the flow of urine before passing the container under the stream to collect the specimen."
"Start the flow of urine before passing the container under the stream to collect the specimen."- This statement is incorrect. The container should be in place before the client begins to urinate to ensure an accurate midstream specimen.
D. "Remove the specimen container before stopping the stream of urine"
"Remove the specimen container before stopping the stream of urine." - This statement is incorrect. The container should be kept in place until the client has finished urinating to avoid contamination of the specimen.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Medsurg Final Proctored Exam. Take the full exam now
Full Explanation
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.
Similar Questions
A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily.
The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?
A. Request an order for an antiemetic.
Request an order for an antiemetic - Checking vital signs is the priority before administering any medication. Antiemetics may be considered later, but the nurse needs to assess the client's overall condition first.
B. Request a dietary consult.
Request a dietary consult - Assessing vital signs comes before consulting for dietary issues.The priority is to determine the client's immediate physiological status.
C. Check the client’s vital signs.
Check the client’s vital signs - This is the correct first action as it helps to evaluate the client's cardiovascular status, especially considering the potential toxicity of digoxin in the setting ofnausea and refusal of breakfast.
D. Suggest that the client rests before eating the meal.
Suggest that the client rests before eating the meal - While rest may be beneficial, assessing vital signs takes precedence to rule out any acute cardiovascular compromise.
Full Explanation
A. Request an order for an antiemetic - Checking vital signs is the priority before administering any medication. Antiemetics may be considered later, but the nurse needs to assess the client's overall condition first.
B. Request a dietary consult - Assessing vital signs comes before consulting for dietary issues.
The priority is to determine the client's immediate physiological status.
C. Check the client’s vital signs - This is the correct first action as it helps to evaluate the client's cardiovascular status, especially considering the potential toxicity of digoxin in the setting of
nausea and refusal of breakfast.
D. Suggest that the client rests before eating the meal - While rest may be beneficial, assessing vital signs takes precedence to rule out any acute cardiovascular compromise.
A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of apneumothorax?
A. Inspiratory stridor
Inspiratory stridor - This is associated with upper airway obstruction and is not indicative of a pneumothorax.
B. Expiratory wheeze
Expiratory wheeze - Wheezing is commonly associated with lower airway conditions such as asthma or chronic obstructive pulmonary disease (COPD), not pneumothorax.
C. Coarse crackles
Coarse crackles - Coarse crackles are typically heard in conditions such as pneumonia or pulmonary edema, not pneumothorax.
D. Absence of breath sounds.
Absence of breath sounds - This is a key manifestation of a pneumothorax. The air in the pleural space can prevent the lung from fully expanding, leading to the absence of breath sounds on the affected side.
Full Explanation
A. Inspiratory stridor - This is associated with upper airway obstruction and is not indicative of a pneumothorax.
B. Expiratory wheeze - Wheezing is commonly associated with lower airway conditions such as asthma or chronic obstructive pulmonary disease (COPD), not pneumothorax.
C. Coarse crackles - Coarse crackles are typically heard in conditions such as pneumonia or pulmonary edema, not pneumothorax.
D. Absence of breath sounds - This is a key manifestation of a pneumothorax. The air in the pleural space can prevent the lung from fully expanding, leading to the absence of breath sounds on the affected side.
A nurse is collecting data from a client whose arterial blood gas values reveal a pH of 7.24, PaCO2 of 53, and an HCO3 of 24. The nurse should prepare to treat the client for which of the following acid-base imbalances?
A. Respiratory acidosis - The low pH (acidosis) and elevated PaCO2 suggest respiratory acidosis, which is caused by inadequate ventilation leading to an accumulation of carbon dioxide.
B. Metabolic acidosis - Metabolic acidosis is characterized by a low pH and decreased HCO3.
C. Respiratory alkalosis - Respiratory alkalosis is characterized by a high pH and low PaCO2, which is not consistent with the provided arterial blood gas values.
D. Metabolic alkalosis - Metabolic alkalosis is characterized by a high pH and increased HCO3, which does not align with the given values.