Nokea
The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply.
- A. I should rinse my mouth with water before collecting the sputum.
- B. I will be careful not to touch the inside of the specimen cup or lid.
- C. I will inhale deeply a few times and then cough forcefully.
- D. It is best to collect the sputum mid-day when my secretions are loose.
- E. It is helpful if I am sitting upright when I collect the sputum.
Correct Answer: A,B,C,E
Rationale: Rinsing the mouth, avoiding contamination, deep coughing, and sitting upright ensure a quality specimen. Morning collection is preferred for higher yield.
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A 54-year-old male is admitted to the cardiac unit with chest pain radiating to the jaw and left arm. Which enzyme would be most specific in the diagnosis of a myocardial infarction?
- A. Aspartate aminotransferase
- B. Lactic acid dehydrogenase
- C. Hydroxybutyric dehydrogenase
- D. Creatine phosphokinase
Correct Answer: D
Rationale: CK-MB (creatine phosphokinase muscle bond isoenzyme) is the most specific for a myocardial infarction. Troponin is also extremely reliable. Answers A, B, and C are nonspecific to myocardial infarctions, so they are incorrect.
The nurse is discussing prostatectomies with a group of men. One man asks which kind of prostatectomy is done for someone who has benign prostatic hyperplasia (BPH). What answer should the nurse give?
- A. Transurethral resection prostatectomy
- B. Suprapubic prostatectomy
- C. Retropubic prostatectomy
- D. Perineal prostatectomy
Correct Answer: A
Rationale: Transurethral resection prostatectomy (TURP) is the most common procedure for BPH, removing prostate tissue via the urethra, minimally invasive compared to open approaches.
The daughter of a 78-year-old woman asks the nurse why her mother is giving away some of her belongings to her children and grandchildren. What should the nurse include when responding?
- A. Older adults usually become more generous.
- B. It is normal for older adults to think about and prepare for their own death.
- C. Her mother probably does not trust her children to divide her things appropriately.
- D. Her mother is probably thinking about suicide.
Correct Answer: B
Rationale: Giving away belongings reflects preparation for death, a normal developmental task in older adults achieving ego integrity. Generosity, distrust, or suicide are less likely.
A client with a recent spinal cord injury is experiencing dysreflexia and is noted to have a BP of $240 / 110$. The nurse's initial response should be to:
- A. Check the client's pulse and respiratory rate.
- B. Elevate the client's head to a $45^{\circ}$ angle.
- C. Place the client flat and supine.
- D. Administer antihypertensive and recheck BP in 15 minutes.
Correct Answer: B
Rationale: Elevating the head to a 45° angle helps reduce blood pressure in autonomic dysreflexia by promoting venous return and reducing intracranial pressure.
The nurse is preparing to administer sumatriptan to a client with a migraine headache. Which of the following findings would require follow-up prior to administering the medication?
- A. BMI of 34 kg/m recorded during today's examination
- B. past medical history of uncontrolled hypertension
- C. takes alprazolam as prescribed for anxiety
- D. BUN of 12 mg/dL (4.28 mmol/L)
Correct Answer: B
Rationale: Sumatriptan is contraindicated in uncontrolled hypertension due to the risk of cardiovascular events.