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When assisting a client to obtain a sputum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next?
- A. Advise the client that suctioning will be used to obtain another specimen
- B. Re-instruct the client in coughing techniques to obtain another specimen
- C. Provide the client a glass of water and mouthwash to rinse the mouth
- D. Label the container and place the container in a biohazard transport bag
Correct Answer: C
Rationale: After observing the client cough and produce frothy saliva in the collection cup, the nurse should provide the client with a glass of water and mouthwash to rinse the mouth. This action helps clear the mouth of contaminants, ensuring a more accurate sputum specimen for diagnostic testing. Option A is incorrect because suctioning is not the appropriate next step in this situation. Option B is unnecessary as re-instructing the client in coughing techniques may not address the immediate issue of contaminated saliva in the specimen. Option D is premature since labeling and transporting the container should only be done after obtaining a valid specimen.
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What is the function of the cervix in reproduction?
- A. Accepts and interprets signals of sexual stimuli
- B. Secretes mucus to facilitate sperm transport
- C. Serves as the site for union of ovum and sperm
- D. Receives the penis during intercourse
Correct Answer: B
Rationale: The cervix functions in reproduction by secreting mucus that facilitates the transport of sperm to the uterus. Choice A is incorrect because the cervix does not interpret signals of sexual stimuli. Choice C is incorrect as the site for the union of ovum and sperm is the fallopian tube. Choice D is incorrect as the cervix is not involved in receiving the penis during intercourse.
A client with a severe peanut allergy accidentally ingested peanut-containing food and is experiencing anaphylaxis. What is the nurse's priority action?
- A. Administer an epinephrine injection
- B. Call for immediate medical help
- C. Monitor airway, breathing, and circulation
- D. All of the above
Correct Answer: A
Rationale: The priority action for a client experiencing anaphylaxis due to a severe peanut allergy is to administer an epinephrine injection. Epinephrine is the first-line treatment for anaphylaxis as it can rapidly reverse the severe allergic reaction. While calling for immediate medical help is important, administering epinephrine takes precedence because it can be life-saving in this situation. Monitoring airway, breathing, and circulation is essential in managing anaphylaxis, but administering epinephrine is the priority action to halt the progression of the allergic reaction and stabilize the client's condition. Therefore, 'Administer an epinephrine injection' is the most critical initial intervention.
A client is prescribed metformin for the management of type 2 diabetes. What is the primary action of this medication?
- A. Stimulates insulin secretion from the pancreas.
- B. Increases insulin sensitivity in various tissues.
- C. Decreases hepatic glucose production.
- D. Delays absorption of glucose from the intestines.
Correct Answer: C
Rationale: The correct answer is C: Decreases hepatic glucose production. Metformin primarily works by reducing the production of glucose in the liver (hepatic glucose production) and by improving insulin sensitivity in various tissues. Choice A is incorrect as metformin does not stimulate insulin secretion from the pancreas. Choice B is incorrect as metformin increases insulin sensitivity in various tissues, not just muscle cells. Choice D is incorrect as metformin does not delay glucose absorption from the intestines.
What should the nurse prioritize when providing discharge instructions to a client with a new colostomy?
- A. Skin care around the stoma site
- B. The schedule for colostomy bag replacement
- C. Techniques for odor control
- D. Dietary modifications
Correct Answer: A
Rationale: Correct answer: Skin care around the stoma site. Proper skin care around the stoma site is crucial for preventing skin irritation and infection, which are common issues for patients with new colostomies. While the schedule for colostomy bag replacement (Option B) is important, it is not the priority during initial discharge instructions. Techniques for odor control (Option C) are relevant but secondary to skin care for a new colostomy. Dietary modifications (Option D) may be discussed later but are not the priority at this stage.
A client is admitted to the hospital with a diagnosis of Pneumonia. Which intervention should the nurse implement to prevent complications associated with Pneumonia?
- A. Encourage mobilization and ambulation
- B. Encourage energy conservation with complete bed rest
- C. Provide humidified oxygen via nasal cannula
- D. Restrict oral (PO) and intravenous fluids
Correct Answer: A
Rationale: The correct intervention to prevent complications associated with pneumonia is to encourage mobilization and ambulation. These activities help prevent complications such as atelectasis by promoting lung expansion. Encouraging energy conservation with complete bed rest (Choice B) is not ideal as it can lead to complications like muscle weakness and decreased lung expansion. Providing humidified oxygen via nasal cannula (Choice C) is important in pneumonia treatment but does not directly prevent complications associated with pneumonia itself. Restricting oral (PO) and intravenous fluids (Choice D) is not recommended as adequate hydration is crucial for pneumonia patients to maintain respiratory function and overall health.