lesson 8 Skin integrity & wound care/Specimen collection and diagnostic testing Flashcards
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client?
A. Eating more protein is optimal prior to testing
B. One still specimen is sufficient for testing’
C. A red color change indicates a positive test
D. The specimen cannot be contaminated with urine
D. The specimen cannot be contaminated with urine
Instruct the client not to contaminate the stool specimens with water or urine.
Incorrect:
A. Eating more protein is optimal prior to testing
Sone proteins can alter the test results, instruct client not to consume red meat, fish, and poultry prior to the test
B. One still specimen is sufficient for testing’
3 specimens are required
C. A red color change indicates a positive test
BLUE result is a positive
Nurse Is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend?
A. Macaroni and cheese
B. One medium apple with skin
C. One cup of plain yogurt
D. Roast chicken and white rice
B. One medium apple with skin
-contains 4.4 grams of fiber
Nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect? SATA
A. Bradycardia
B. Hypotension
C. Elevated Temperature
D. Poor Skin turgor
E. Peripheral edema
B. Hypotension
C. Elevated Temperature
D. Poor Skin turgor
while a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take?
A. Have the client had their breath briefly and bear down
B. clamp the enema tubing
C. Remind the client that cramping is common at this time
D. Raise the level of the enema fluid container
B. clamp the enema tubing
clamp the enema tubing for 30 seconds to reduce intestinal spasms
Nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? SATA
A. Warm the enema solution prior to instillation
B. Position the client on the left side with the right leg flexed forward
C. Lubricate the rectal the rectal tube about 5 cm (2”)
D. Slowly insert the rectal tube about 5 cm (2 in)
E. Hand the enema container 61cm (24”) above the client’s anus.
A. Warm the enema solution prior to instillation
(warm the enema solution because cold fluid can cause abdominal cramping, and hot fluid can injure intestinal mucosa)
B. Position the client on the left side with the right leg flexed forward
C. Lubricate the rectal the rectal tube about 5 cm (2”)
Incorrect:
D. Slowly insert the rectal tube about 5 cm (2 in)
(correct length of insertion for a child is 5cm(2in). For an adult client 7.6 to 10.2 (3-4”)
E. Hand the enema container 61cm (24”) above the client’s anus.
(should be 18”)
Nurse is teaching a client who reports stress urinary incontinence. which of the following instructions should the nurse include? SATA
a. Limit total daily fluid intake
b. Decrease or avoid caffeine
c. take calcium supplements
d. avoid drinking alcohol
e. use the creed maneuver
b. Decrease or avoid caffeine
d. avoid drinking alcohol
Caffeine and alcohol is a bladder irritant can worsen stress incontinence
Incorrect:
a. Limit total daily fluid intake
because stress incontinence results from weak pelvic muscles and other structures, limiting fluids will not resolve the problem.
c. take calcium supplements
(no effect on stress incontintence )
e. use the creed maneuver
(helps manage reflex reflex incontinence, not stress incontinence)
Client who had an indwelling catheter reports a need to urinate. Which of the following should the nurse take?
a. check to see whether the catheter is patent
b. reassure the client that it is not possible for them to urinate
c. recatheterize the bladder with a larger-gauge catheter
d. collect a urine specimen for analysis
Nurse is caring for a client who has a prescription for a 24hr urine collection. Actions should the nurse take?
a. Discard is first voiding
b. keep the urine in a single container at room temp
c. dispose the last voiding
d. ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container
a. Discard is first voiding
discard after the first voiding of the 24hour urine, and note the time.
INCORRECT
b. keep the urine in a single container at room temp
(should be kept in the refrigerator)
c. dispose the last voiding
(advise client to completely empty the bladder, and save the last voiding at the end of collection period)
d. ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container
the urine should not be stopped. client urinate first into toilet and insert the specimen cup during midstream to collect specimen.
Nurse is reviewing factors that increase the risk of UTIs with a client who has recurrent UTIs. Which of the following factors should the nurse include? SATA
a. frequent sexual intercourse
b. lowering of testosterone levels
c. wiping from front to back to clean the perineum
d. location of the uretha closer to the anus
e. frequent catheter
a. frequent sexual intercourse
(increases the risk of UTIs)
d. location of the uretha closer to the anus
(close proximity of the uretha to anus is a factor that increases risk of UTI
e. frequent catheter
(frequent catheters and indwelling caths are risk factor for UTIs
INCORRECT:
b. lowering of testosterone levels
c. wiping from front to back to clean the perineum
Nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. which of the following actions should the nurse take? SATA
a. restrict the clot’s intake of fluids during the daycare
b. have the client record urination times
c. gradually increase the urination intervals
d. remind the client to hold urine until the next scheduled urination time.
e. provide a sterile container for urine.
b. have the client record urination times
(ask the client to keep track of urination times as. record of progress toward the goal of 4 hr intervals between urination.)
c. gradually increase the urination intervals
(gradually increasing the urination times as a record of progress toward the goal of 4hr intervals between urination.
d. remind the client to hold urine until the next scheduled urination time.
(remind the client to hold urine until the next scheduled urination time as part of progressing toward the goal of 4hr intervals between urination.
Nurse is reviewing the medical record of a client who has a blood glucose of 260mg/dl and no documented history of diabetes mellitus. Which of the following types of medications can cause hyperglycemia as an adverse effect? SATA
a. Diuretics
B. Corticosteroids
c. Oral anticoagulants
d. Opioid analgesics
e. Antipsychotics
a. Diuretics
cause hyperglycemia, esp in clients who have diabetes mellitus and also can cause may electrolyte imbalances
B. Corticosteroids
can cause hyperglycemia and glycosuria
e. Antipsychotics
can cause new onset diabetes mellitus, particularly antipsychotics.
INCORRECT:
c. Oral anticoagulants
can cause excessive bleeding during blood sampling for glucose testing
d. Opioid analgesics
can cause respiratory depression , but they are unlikely to raise blood glucose testing.
Nurse teaching a client how to check blood glucose levels. The nurse should include which of the following instructions about transferring blood unto the reagent portion of the test strip?
a. smear the blood on the strip
b. squeeze the blood unto the strip
c. tough the puncture to stimulate bleeding
d. hold the test strip next to the blood on the fingertip
d. hold the test strip next to the blood on the fingertip
Incorrect:
a. smear the blood on the strip
-smearing the blood on the test strip can cause inaccurate results
b. squeeze the blood unto the strip
-client should milk the finger gently to obtain a drop of blood. forceful milking or squeezing can cause pain, bruising, scarring
c. tough the puncture to stimulate bleeding
- touching the puncture site can cause transfer of micro-organism to the site
Nurse attempting to collect a capilary blood specimen via finger stick for blood glucose monitoring is unable to obtain adequate drop of blood for the reagent strip. Which of the following actions should the nurse take first?
a. puncture another finger to obtain a capillary specimen
b. test the urine with a urine reagent strip
c. wrap the hand in a warm, moist cloth
d. perform a venipuncture to obtain a venous sample
c. wrap the hand in a warm, moist cloth
-when providing client care, first use the least invasive intervention. Warm the client’s finger with a warm, moist cloth to promote blood flow in preparation for the next finger stick.
INCORRECT:
a. puncture another finger to obtain a capillary specimen
-another finger can be punctured to obtain a capillary specimen. However, use a less invasive intervention first.
b. test the urine with a urine reagent strip
-urine glucose can be obtained . however the client’s blood glucose level should be significantly elevated in order to detect glucose in the urine. use less invasive intervention 1st.
d. perform a venipuncture to obtain a venous sample
-Venipucture might need to be requested for checking the blood glucose level. however, use a less invasive intervention first.
Nurse is teaching self monitoring of blood glucose (SMBG) to a client who has diabetes mellitus. Which of the following instructions should the nurse include? SATA
a. Perform SMBG once daily at bedtime
b. wipe the hand with an alcohol swab
c. Hold the hand in a dependent position prior to puncture
d. place the puncturing device perpendicular to the site
e. prick the outer edge of the fingertip for the blood sample
c. Hold the hand in a dependent position prior to puncture
-client should hold the hand in a dependent position to increase the blood flow to the fingers.
d. place the puncturing device perpendicular to the site
- the client should hold the lancet perpendicular to the skin to ensure the correct piercing depth.
e. prick the outer edge of the fingertip for the blood sample
-the client should use the outer edge of the fingertip for blood sampling. The client can also use a heel, palm, arm or thigh.
Incorrect
a. Perform SMBG once daily at bedtime
-usually performed as often as before each meal and at bedtime. generally the timing and frequency of SMBG testing correlates with the client’s medication schedule.
monitoring once daily at bedtime does not provide enough info to monitor blood glucose control effectively .
b. wipe the hand with an alcohol swab
-client should wash their hands with warm soap and water. alcohol can alter the blood glucose control effectively .
