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Which actions should the nurse take when obtaining a sputum culture from a client with a diagnosis of pneumonia? Select all that apply.
- A. Explain the procedure to the client.
- B. Obtain the specimen early in the morning.
- C. Have the client brush his teeth before expectoration.
- D. Instruct the client to take deep breaths before coughing.
- E. Place the lid of the culture container face down on the bedside table.
Correct Answer: A,B,C,D
Rationale: The nurse always explains a procedure to the client. The specimen is obtained early in the morning whenever possible because increased amounts of sputum collect in the airways during sleep. The client should rinse the mouth or brush the teeth before specimen collection to avoid contaminating the specimen. The client should take deep breaths before expectoration for best sputum production. Placing the lid face down on the bedside table contaminates the lid and could result in inaccurate findings.
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The nurse has a prescription to administer foscarnet sodium intravenously to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). Before administering this medication, which measure should the nurse implement?
- A. Obtain a sputum culture.
- B. Obtain folic acid as an antidote.
- C. Place the solution on a controlled infusion pump.
- D. Ensure that liver enzyme levels have been drawn as a baseline.
Correct Answer: C
Rationale: Foscarnet sodium is an antiviral agent used to treat cytomegalovirus (CMV) retinitis in clients with AIDS. Because of the potential toxicity of the medication, it is administered with the use of a controlled infusion device. A sputum culture is not necessary. Folic acid is not an antidote. Foscarnet sodium is highly toxic to the kidneys, and serum creatinine levels are measured frequently during therapy, not liver enzymes.
The nurse is preparing to administer prescribed heparin sodium 5000 units subcutaneously. Which action should the nurse take to safely administer the medication?
- A. Inject via an infusion device.
- B. Inject within 1 inch of the umbilicus.
- C. Massage the injection site after administration for a full minute.
- D. Change the needle on the syringe after withdrawing the medication from the vial.
Correct Answer: D
Rationale: After withdrawal of heparin from the vial, the needle is changed before injection to prevent leakage of medication along the needle tract. Heparin administered subcutaneously does not require an infusion device. The injection site is located in the abdominal fat layer. It is not injected within 2 inches of the umbilicus or into any scar tissue. The needle is withdrawn rapidly, pressure is applied, and the area is not massaged. Injection sites are rotated.
A pregnant client tests positive for the hepatitis B virus. The client asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which therapeutic response should the nurse communicate to the client?
- A. You will not be able to breast-feed the baby until 6 months after delivery.
- B. Breast-feeding is not advised, and you should seriously consider bottlefeeding the baby.
- C. Breast-feeding is not a problem, and you will be able to breast-feed immediately after delivery.
- D. Breast-feeding is allowed if the baby receives prophylaxis treatment at birth and scheduled immunizations.
Correct Answer: D
Rationale: The pregnant client who tests positive for hepatitis B virus should be reassured that breast-feeding is not contraindicated if the infant receives prophylaxis at birth and remains on the schedule for immunizations. Therefore, options 1, 2, and 3 are incorrect.
The nurse is assigned to care for a hospitalized toddler. Which measure should the nurse plan to implement as the highest priority of care?
- A. Providing a consistent caregiver
- B. Protecting the toddler from injury
- C. Adapting the toddler to the hospital routine
- D. Allowing the toddler to participate in play and diversional activities
Correct Answer: B
Rationale: The toddler is at high risk for injury as a result of developmental abilities and an unfamiliar environment. Although consistency, adaptation, and diversion are important, protection from injury is the highest priority.
A client asks the home care nurse to witness the client's signature on a living will with the client's attorney in attendance. Which action is most appropriate for the nurse to implement?
- A. Decline to witness the signature on the living will.
- B. Sign the living will as a witness to the signature only.
- C. Notify the supervisor that a living will is being witnessed.
- D. Sign the living will with identifying credentials and employment agency.
Correct Answer: A
Rationale: Living wills are written documents and need to be signed by the client. The client's signature must be either witnessed by nonagency individuals or notarized; thus, the nurse should decline to sign the will to avoid a conflict of interest. There is no need to contact the supervisor or sign the living will with or without credentials because the nurse cannot sign this document as a witness. Therefore, options 2, 3, and 4 are incorrect.