Chapter 09: Specimen Collection

The patient's blood glucose level was 134 mg/dL at 7 AM and is now 61 mg/dL at 3 PM. Which intervention should the nurse implement first? q. Assess the patient for confirmatory findings. r. Check calibration of the blood glucose meter. s. Administer insulin according to a sliding scale. t. Instruct the patient to have orange juice and crackers.

ANS: A As long as the patient is not in acute distress, the nurse assesses the patient for hypoglycemia to determine whether the patient presentation matches the glucose results. If the nurse determines that the patient has clinical indicators of hypoglycemia, the nurse incorporates these findings to form a plan of suitable nursing interventions. Checking the calibration of the device is a reasonable intervention if it appears that there are no confirming findings for the reading. Insulin drives glucose into the cells, further decreasing blood sugar. Until the reading is confirmed, it is not clear that providing supplemental calories to elevate blood sugar is appropriate.

The nurse is reviewing the findings from a basic analysis of gastric secretions. What information would the nurse expect to find? a. Negative occult blood b. Black coloration of gastric secretions c. Clumps or clots of blood d. "Coffee-ground" secretions

ANS: A The nurse expects to find no evidence of gastric bleeding with gastric secretion analysis because the normal stomach lining is a thick layer of mucus. Black coloration, clumps or clots of blood, or "coffee-ground" secretions are all unexpected findings and are evidence of bleeding.

The nurse is preparing to obtain a blood specimen. Which is the most important intervention for the nurse to complete before obtaining a blood specimen? e. Verify patient identification. f. Perform patient skin preparation. g. Ask the patient for an arm preference. h. Tell the patient that the procedure is slightly painful.

ANS: A The nurse verifies patient identification before obtaining the blood specimen and uses at least two patient identifiers to ensure accurate identification because the nurse exposes the patient to potentially life-threatening complications by mislabeling a specimen. Skin preparation occurs only after the patient has been identified correctly. The remaining interventions are helpful, but only after the patient has been correctly identified.

The nurse is trying to obtain urine from a pediatric patient for a urine culture. What is the smallest amount of urine the nurse needs to obtain from a patient for a urine culture? ss. 3 mL tt. 5 mL uu. 10 mL vv. 20 mL

ANS: A The smallest amount required for a urine culture is 3 mL.

The nurse is teaching a NAP to test urine with a reagent strip for chemical properties. Which technique demonstrated by the NAP would indicate understanding of the process? gg. Immerse the reagent strip in urine for 1 minute. hh. Compare reagent strip to the color chart on the bottle. ii. Obtain the patient's first voided specimen in the morning. jj. Add a chemical tablet to the urine and then test with a reagent strip.

ANS: B After immersing the reagent strip in the patient's urine and removing quickly, the nurse waits the exact number of seconds recommended before comparing the strip to the color chart on the bottle. The nurse avoids comparing the strip too early because the chemical reaction necessary to complete the test takes time to process. The first voided specimen of the day is frequently used for testing; however, the nurse obtains a urine specimen according to the provider's prescription. Reagent strips are one-step procedures.

The nurse is monitoring the collection of a 24-hour urine specimen. What action by the nurse will yield the most accurate test results? cc. Keep the patient on the unit during the test. dd. Keep the urine in a collection bottle in a container of ice. ee. Save all urine from the time the test begins. ff. Leave the collection bottle in the patient's bathroom.

ANS: B Keeping the urine on ice prevents it from decomposing. The ice needs to be maintained throughout the entire test. As the ice melts, the cold water is poured out, and more ice is replaced so the entire level of urine is below the level of ice. The patient can leave the unit during testing, and the nurse notifies receiving personnel to save all urine. The nurse instructs the patient to void just before beginning so the patient starts the test with an empty bladder.

During a home visit, the patient with diabetes mellitus tells the nurse that she is having a very difficult time obtaining blood for glucose monitoring. Which intervention does the nurse use to help the patient obtain a good blood sample? a. Asks the health care provider to order a different monitoring device. b. Instructs the patient to position the lancet on the side of finger or forearm. c. Teaches the patient to find a good site and use it repeatedly. d. Tells the patient to run warm water over the hand before testing.

ANS: B The nurse eliminates all patient-related factors that potentially interfere with glucose monitoring such as technique, dexterity, vision, or lack of knowledge. Regardless of the device being used for glucose testing, if the patient has difficulty implementing the procedure, changing devices is potentially futile if the same mistakes are repeated. Thus the nurse assists the patient with proper lancet positioning on the side of the finger or forearm to obtain enough blood for glucose monitoring. If the patient lacks experience with the lancet, has a long history of glucose monitoring that causes accumulation of scar tissue at puncture sites, or avoids deep punctures because of pain, he or she requires teaching to refine and reinforce the proper technique for obtaining a blood droplet. The nurse avoids suggesting warm water because patients with diabetes often have neuropathies and vasculopathies as complications of hyperglycemia; thus the patient is likely to have impaired tissue perfusion and sensation to extremities.

A newly diagnosed patient with diabetes is being taught the procedure for obtaining a blood glucose specimen. What information should the nurse include in patient teaching about the procedure for capillary puncture? a. Puncture the center of the fingertip. b. Allow the alcohol to dry completely. c. Hold the finger upright for the puncture. d. Squeeze the finger to increase blood flow.

ANS: B The nurse instructs the patient to allow the alcohol or other antiseptic time to dry before puncturing the skin because the drying kills the microorganisms and the needle can carry alcohol into the puncture, increase the pain, and skew the results. The least painful sites to puncture the fingertip are on the sides. The patient should be told to hold the finger in a dependent position before puncturing to engorge the fingertip with blood. Squeezing the finger has the potential to skew the results of the testing.

The nurse notices a change in wound drainage and gets an order for a culture. Nursing care is appropriate if which technique is used? ww. Obtain samples of both skin and wound exudate. xx. Rotate sterile swabs at a deep point in the wound. yy. Use older secretions for a more valid specimen. zz. Move the swabs back and forth across the wound.

ANS: B To obtain a wound culture, the nurse rotates the sterile aerobic and anaerobic swabs deep within the wound to obtain a sample of wound exudate that potentially has not yet reached the wound edges. Moving the swab in a back-and-forth motion risks cross-contamination. The nurse avoids contaminating the wound culture with normal skin flora. The nurse also avoids using older secretions from the wound because the older secretions do not reflect the status of the wound.

A test for occult blood is to be done tomorrow. Patient teaching by the nurse has been appropriate if the patient chooses which menu for dinner tonight? aaa. Hamburger, noodles, dinner roll with butter, broccoli bbb. Beef stew, rice, garlic bread, applesauce ccc. Macaroni and cheese, mixed vegetables, apple slices ddd. Pork chop, mashed potatoes with gravy, peas, ice cream

ANS: C A diet free of red meat for 24 hours prior to collecting the sample helps to prevent a false-positive result when testing for occult blood. There is no meat in the menu selection, and it contains several high-fiber choices.

The nurse evaluates the venipuncture site before leaving the patient's room with the blood specimen. Which nursing observation is an unexpected outcome? i. A dot of blood covers the venipuncture site. j. Heart rate is stable and regular at 80 beats/min. k. A soft subcutaneous lump appears at the venipuncture site. l. The patient complains of stinging with removal of the needle.

ANS: C A soft subcutaneous lump at the venipuncture site after withdrawing the needle potentially indicates hematoma formation; this is undesirable because it increases the risk of patient infection at the site and is likely to cause patient discomfort. A dot of blood can indicate leakage from the venipuncture site but is usually a benign finding indicating clot formation. A stable heart rate and rhythm is a highly desirable outcome of venipuncture. Stinging on removal of the needle is expected.

A nurse is orienting another nurse to the procedures for collecting blood samples. Which statement indicates that the orientee needs further education? u. "The tourniquet is placed so it can be removed by pulling one end." v. "A healthy vein is elastic and rebounds on palpation." w. "The specimen is labeled with only the patient's name." x. "I clean the area with antiseptic swabs first."

ANS: C All specimens are labeled with two forms of patient identification. After you collect the specimen and in the presence of the patient, you must label the container itself (not the lid) with the same two identifiers (e.g., patient name and hospital identification number), specimen source, collection date and time, series number (if more than one specimen), and anatomical site if appropriate (e.g., wound culture from knee versus abdominal incision). The other statements are all accurate for the methods involved in obtaining a blood specimen.

The nurse is obtaining a nasal culture using a commercially prepared culture tube. After placing the swab in the culture tube, what should the nurse do next? kk. Take the swab and mix it in reagent to check for color changes. ll. Place the swab into a culture tube and add a reagent to the tube. mm. Label the specimen and enclose it in a plastic biohazard bag. nn. Place the swab into the tube, close it securely, and keep it warm.

ANS: C Specimens must be properly labeled to avoid diagnostic and therapeutic errors. The nurse cannot evaluate the results of the culture; the fluid captures the microorganisms, and the technician mounts the fluid on slides and visualizes the specimen under the microscope. The nurse avoids adding reagents to the tube, then refrigerates the specimen after properly releasing the fluid.

The patient accidentally discards voided urine during a 24-hour urine collection. What should the nurse do next? a. Instruct the patient to call for help before voiding. b. Consult with the laboratory for further instructions. c. Discard all urine and begin another 24-hour collection. d. State on the laboratory requisition that one specimen is missing.

ANS: C The 24-hour specimen is invalid, so the nurse starts a new collection and reinforces instructions to the patient. A new container is obtained, and the collection is restarted. The nurse cannot send the specimen to the laboratory missing one specimen because the urine sent does not contain all urine from the last 24 hours.

The health care provider orders a urine test. Which is the most important information for the nurse to consider before collecting the urine specimen needed for the test? a. That the specimen collection precedes antibiotic administration. b. That the urine aspirated from the collection bag is suitable. c. Whether the urine test requires sending a sterile specimen. d. Whether the patient can provide peri-care properly.

ANS: C The most important information for the nurse to know is whether the specimen needs to be sterile. If the test requires a sterile specimen, the nurse uses sterile technique to collect an uncontaminated specimen. If not, collecting the specimen with clean technique is adequate. The patient's ability to cleanse the perineum or whether to use urine aspirate are decisions answered by determining if the procedure needs to be sterile. If the urine sample is for a culture and sensitivity, it should be collected prior to administering antibiotics, but the question is asking about any urine sample.

The patient has an indwelling urinary catheter. What step should the nurse take first to obtain a urine specimen from this patient? a. Apply sterile gloves for the procedure. b. Insert a small needle into the drainage tubing. c. Clamp the drainage tubing for several minutes. d. Disconnect the catheter and drain the urine into the cup.

ANS: C The nurse clamps the clear drainage tubing below the self-sealing sampling port for 10-30 minutes before collecting a urine specimen from an indwelling urinary catheter to allow accumulation of fresh urine. Sterile gloves are needed for the perineal preparation for a voided urine specimen; this specimen will come from the catheter. Inserting a needle into the drainage tubing potentially causes a crack or a leak in the tubing because the tubing is not designed for puncturing. The nurse avoids disconnecting any sterile drain unless necessary.

The nurse is preparing to obtain a blood specimen. Which step should the nurse implement when preparing for venipuncture? a. Tie the tourniquet in a knot. b. Use the tourniquet for at least 1 minute. c. Place the tourniquet 5-10 cm (3-4 inches) above the selected site. d. Apply the tourniquet tight enough to occlude distal pulses.

ANS: C The nurse places the tourniquet around and above the selected site by 5-10 cm (3-4 inches) and tightens the tourniquet enough to occlude venous return but not distal pulses. A slipknot or a Velcro strip should be used for a quick, one-handed release of the tourniquet. The nurse should try to have the tourniquet in place for no longer than a minute, depending on the patient. The nurse is able to occlude the venous return without occluding arterial blood flow because the arterial system is a higher-pressure system and thus requires more pressure to stop blood flow than a vein requires.

While the nurse tries to obtain a sputum specimen from the patient who has pneumonia, the patient becomes short of breath, and the respiratory rate increases. Which intervention does the nurse implement next? a. Completes the sputum collection quickly b. Clears the patient's airway with suctioning c. Provides prescribed supplemental oxygen d. Instructs the patient to lie flat and breathe deeply

ANS: C The nurse stops the procedure; provides supplemental oxygen; and instructs the patient to take several slow, deep breaths to restore oxygen saturation. Collection of the sputum is now secondary to the oxygenation level. The patient must be stabilized first; then the collection can continue. Suctioning is only appropriate when the airway is compromised. The nurse helps the patient to semi-Fowler's or high-Fowler's position, whichever is most comfortable for the patient, to facilitate chest expansion. The nurse avoids the supine position because lying flat increases the work of breathing.

The nurse obtains blood specimens in the clinic and prefers using an antecubital vein. Which characteristics of veins in this area justify the nurse's preference for the antecubital site? a. It is easily accessed in the hand. b. It causes less pain and bleeding. c. It is large, straight, and close to the surface. d. It is superficial and the most distal.

ANS: C The nurse uses the antecubital area for blood draws because these veins are superficial, large, straight, and well anchored; these characteristics increase the chances of a successful blood draw on the first puncture. The antecubital area does not include the hand. Except for punctures in the hand, venipunctures tend to cause the same degree of pain and bleeding, regardless of the location. The most distal veins in the arm are located in the hand, and these veins are reserved for IV fluids.

The nurse is teaching a patient about the proper procedure for testing stool for occult blood. The nurse's teaching has been effective if the patient makes which statement? m. "I apply a very thick smear of stool onto the guaiac slide." n. "The electronic meter calculates a reading within minutes." o. "It is best if I get two separate samples from the same stool." p. "I call my doctor for white paper with stool and developer on it."

ANS: C The patient is correct to say that more than one sample from the stool specimen is required for more conclusive results because occult blood from the gastrointestinal tract is not always equally dispersed through the stool. A thin smear is adequate for testing. An electronic meter is not used for guaiac testing. The stool is not placed on the paper until the patient is actually ready to test a sample.

A patient in the doctor's office needs a throat culture. What should the nurse implement to obtain a proper sample? a. Instruct the patient to lie flat and tilt head. b. Ensure the patient has been NPO. c. Avoid touching the swab to any inflamed areas. d. Depress the anterior third of the tongue

ANS: D The nurse depresses the anterior third of the patient's tongue to minimize the gag reflex. The patient sits upright and tilts the head back for the test. The patient does not need to be NPO, however; if the patient has recently eaten, gagging may produce emesis. The nurse obtains a swab of the inflamed area, which is the area most likely to be infected.

A patient is unable to void on demand for a clean-voided specimen. What is the appropriate action by the nurse? a. Notify the provider that the patient has anuria. b. Palpate the suprapubic area for retained urine. c. Catheterize the patient to obtain the urine specimen. d. Offer fluids, if allowed, and wait about 30 minutes.

ANS: D The nurse encourages the patient to drink fluids to fill the bladder so the patient can produce a clean-voided urine specimen. The nurse implements this first because it is noninvasive and it is the most likely cause of being unable to void. Notifying the health care provider of anuria is premature. Palpating the bladder to determine urine volume is inappropriate for this procedure. Catheterizing is an invasive procedure and increases the risk of patient infection.

The nurse is obtaining a sputum specimen from a patient without using suction. What should the nurse have the patient do to produce enough sputum for a sample? oo. Instruct the patient to obtain specimens over 4 hours. pp. Try to obtain a sample immediately after eating. qq. Rinse the mouth with water to loosen the mucus. rr. Take several deep breaths and forcefully cough into a sterile container.

ANS: D The nurse instructs the patient to take three to four deep breaths before expectorating; the series of deep breaths helps to mobilize secretions and increases the chance of obtaining sputum in a sufficient quantity. The nurse instructs the patient to produce 5-10 mL of sputum and sends the specimen directly to the laboratory before potential degradation. A specimen obtained immediately after a meal is likely to be contaminated with food or saliva. The nurse offers clear water for oral rinsing before asking the patient to provide a sputum specimen because toothpaste or mouthwash potentially kills pathogens that cause infection and skews the results of the culture.

A female patient needs to provide a midstream-voided urine specimen for examination. What teaching by the nurse would provide a valid specimen? y. Use a clean specimen cup for testing. z. Collect at least 125-150 mL of urine. aa. Wash the perineal area with soap and water. bb. Void some urine and then collect the sample.

ANS: D The nurse instructs the patient to void a small amount of urine and then pass the sterile container under the urine stream to collect urine for a clean-voided urine specimen. A sterile specimen container, not a clean container, is used. Urine testing requires 30-60 mL of urine. The nurse provides three antiseptic wipes or cotton balls or gauze soaked in antiseptic solution for perineal cleansing in preparation for the specimen collection.

The nurse is preparing to draw a blood sample. Which technique should the nurse implement when performing venipuncture? a. Insert the needle, bevel up, at a 45-degree angle. b. Select a vein that is rigid, cordlike, and prominent. c. Insert the needle at once after scrubbing the skin with alcohol. d. Pull the skin taut by placing the thumb about 2.5 cm (1 inch) below the site.

ANS: D The nurse stabilizes the vein and minimizes rolling by pulling the vein with the thumb positioned about 1 inch below the insertion point to prevent contaminating the site. The needle is inserted at a 15- to 30-degree angle. The best vein to select will be prominent and straight with no signs of swelling or hematoma. The vein should rebound when palpated. The nurse allows the alcohol to dry before inserting the needle because the process kills microorganisms and the needle can carry alcohol into the puncture and increase the pain.

The nurse is preparing a patient with peptic ulcer disease for discharge to home. What information does the nurse include in patient teaching about testing stool for occult blood? a. Positive results indicate active bleeding. b. It is necessary to eat poultry and fish before testing. c. Each stool specimen provides one sample for testing. d. Menstruation postpones the testing for occult blood.

ANS: D When the patient is menstruating, testing for occult blood is ineffective because the test does not discriminate between menstrual blood and occult blood from the gastrointestinal tract. The nurse instructs the patient to wait until blood flow ceases, provide self-care of the perineum, and then test for occult blood. Positive results indicate the presence of blood but do not distinguish between new or old blood. The patient does not have to eat fish or poultry before testing but avoids red meat because it potentially increases the redness of stool. Each stool specimen provides two samples for testing.