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The nurse is preparing to collect a sputum specimen from the client suspected of having tuberculosis. What is the correct method for obtaining a sputum specimen?
- A. Collect the specimen in the morning prior to breakfast.
- B. Collect the specimen on three consecutive days.
- C. Transport the collected specimen to the laboratory immediately.
- D. Offer mouth care after collecting the sputum specimen.
- E. Allow the client to rinse his mouth with an antiseptic solution prior to the sputum collection.
Correct Answer: A, B, C, D
Rationale: Morning collection (A) yieldsthough sputum is most concentrated. Three consecutive days (B) ensure reliable tuberculosis diagnosis. Immediate transport (C) prevents degradation. Mouth care (D) maintains hygiene. Antiseptic rinse (E) may kill bacteria, invalidating the sample.
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The nurse is caring for a client with a history of a pneumothorax who is being discharged. The nurse should teach the client to:
- A. Resume heavy lifting
- B. Avoid swimming
- C. Report chest pain immediately
- D. Sleep on the affected side
Correct Answer: C
Rationale: Chest pain post-pneumothorax may indicate recurrence or complications, requiring immediate reporting. Heavy lifting and swimming are restricted, and sleeping position is not critical.
A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:
- A. Encourage him to drink plenty of fluids
- B. Expect him to have nausea with vomiting
- C. Keep him awake for the next 12 hours
- D. Wake him up every 1-2 hours during the night
Correct Answer: D
Rationale: If the child cannot be awakened from sleep after head injury, it is an indication of serious increase in ICP. The mother should call an ambulance right away.
The client is admitted with a diagnosis of acute diverticulitis. Which dietary order should the nurse anticipate?
- A. High-fiber diet
- B. Low-residue diet
- C. Clear liquid diet
- D. Regular diet
Correct Answer: C
Rationale: A clear liquid diet is ordered during acute diverticulitis to rest the bowel and reduce irritation. High-fiber is for prevention, low-residue is for chronic management, and regular diets are inappropriate.
One of the medications that is prescribed for a male client is furosemide (Lasix) 80 mg bid. To reduce his risk of falls, the nurse would teach him to take this medication:
- A. On arising and no later than 6 PM
- B. At evenly spaced intervals, such as 8 AM and 8 PM
- C. With at least one glass of water per pill
- D. With breakfast and at bedtime
Correct Answer: A
Rationale: Taking furosemide early in the day minimizes nighttime urination, reducing fall risk. The other options increase nighttime bathroom trips or are irrelevant to fall prevention.
Which of the following statements describes Piaget's stage of concrete operations?
- A. Reflex activity proceeds to imitative behavior.
- B. The ability to see another's point of view increases.
- C. Thought processes become more logical and coherent.
- D. The ability to think abstractly leads to logical conclusion.
Correct Answer: C
Rationale: Piaget's concrete operations stage (ages 7-11) involves logical, coherent thinking about concrete events, not abstract concepts. Perspective-taking improves but is secondary to logical thought.