Specimens, Ostomy care

The nurse is preparing to perform a nasopharyngeal swab for a client. The client asks approximately how far the nurse will insert the swab. What will the nurse tell the client?

"6 inches (15 centimeters)."

The nurse has presented an educational inservice about collection of sputum specimens and ask participants, "When is the best time to collect a sputum specimen?" Which response by a participant indicates a correct understanding of the material?

"First thing in the morning when the client wakes up"

The nurse is preparing to perform a nasopharyngeal swab for a client. The client asks approximately how far the nurse will insert the swab. What will the nurse tell the client? a) "Toward the left side of the nasal cavity." b) "Upward toward the roof of the nasal cavity." c) "Posteriorly along the floor of the nasal cavity." d) "Toward the right side of the nasal cavity."

"Posteriorly along the floor of the nasal cavity."

The nurse is assisting the client with collection of a sputum specimen. The client asks the nurse why it is necessary to rinse the mouth with water before beginning the procedure. How should the nurse respond?

"Water will help to rinse the oral cavity of excess saliva and any food particles."

The nurse is preparing to empty an open-ended colostomy pouch. Place in order the steps the nurse would take. Use all options. a) Uncuff the edge of the pouch b) Apply the clamo c) Fold the end of the pouch upward like a cuff d) Wipe the lower 2 in (5 cm) of the pouch with toilet tissue e) Empty the contents into a measuring device

1) Fold the end of the pouch upward like a cuff. 2) Empty the contents into a measuring device. 3) Wipe the lower 2 in (5 cm) of the pouch with toilet tissue. 4) Uncuff the edge of the pouch. 5) Apply the clamp.

Prior to performing a nasopharyngeal swab for a client, the nurse should make the client aware that the swab will be in the nasopharynx for how long before removing?

15 to 30 seconds

The nurse is performing a nasal swab for a client. To ensure client comfort and safety, how far will the nurse insert the swab into the nare?

2 cm

The nurse has a prescription to test a female client's stool for occult blood. The client just finished her menstrual cycle. How long should the nurse wait before testing stool for occult blood for this client?

3 days

A nurse is testing stool for occult blood. The client wants to know how long it will take to know the results. The nurse tells the client that after applying the developer to the sample, the result will be read in how many minutes?

5 minutes

The nurse is educating a client prior to performing a nasal swab for the client to know what to expect. The nurse tells the client that after inserting the swab into the nare, the nurse will rotate the swab how many times?

5 rotations

A charge nurse is explaining to a new nurse the procedure for obtaining a nasopharyngeal swab. Which statement should the charge nurse make? a) The swab should be inserted no more than 3 in (7.5 cm) in an adult. b) The technique is primarily used for detection of fungal infections. c) Sneezing often occurs when the swab touches the posterior nasopharynx. d) A flexible wire with a cotton tip is used to obtain the sample.

A flexible wire with a cotton tip is used to obtain the sample.

The nurse is assisting a client with changing an ostomy appliance. What is the best method of ensuring that the client has understood the procedure and is able to perform it independently?

After performing the first appliance change, observe the client performing the next change.

The nurse is instructing a client in proper technique for collecting a midstream urine sample. The client reports having voided only a short while ago and is concerned there may not be a sufficient volume of urine. Which amount of urine would the nurse instruct the client is necessary for testing to be performed?

Approximately 1.5 tablespoons (10 to 20 mL)

The nurse needs to collect a stool specimen for culture from a client. The client has been having watery stools for several days and asks if a sample can still be tested since stool is not formed. What is the best response by the nurse?

As long as the specimen is an adequate amount, even liquid stool can be tested."

The nurse is preparing to collect a urine specimen from a client's indwelling urinary catheter. Which technique should the nurse plan to use?

Attach a sterile syringe to the luer-lock sampling port on the catheter drainage tubing and withdraw urine.

The nurse is collecting a urine sample from an indwelling urinary catheter. Prior to cleaning the aspiration port, what would be the appropriate nursing action?

Bend the drainage tubing back on itself distal to the port.

The nurse is monitoring a client with a colostomy and notices that the ostomy appliance is leaking. What would be the appropriate nursing action in this situation?

Change the appliance immediately.

The nurse is explaining the procedure for collecting a midstream urine specimen to a female client capable of performing the procedure without assistance. How should the nurse instruct the client to cleanse the perineal area prior to collecting the sample?

Clean each side of the urinary meatus then cleanse over it.

The nurse is observing a client learning to change the ostomy appliance. Which action by the client would require the nurse to intervene?

Client cuts the opening on the new bag 0.5 in (1.25 cm) larger than the stoma size. [client should cut the opening 0.125 in (0.625 cm) larger than the stoma size]

When obtaining a urine specimen from an indwelling urinary catheter, the nurse places a label on the specimen container. How should the nurse check the information on the specimen label?

Compare it to the client identification band.

The nurse is changing a colostomy bag for a client and notices that there is minor bleeding coming from the stoma. What is the recommended action in this situation?

Continue the procedure, because this is a common finding during stoma care.

The nurse is caring for a client who collected a sputum specimen by oneself at the bedside. The client cannot recall when the specimen was collected or how long it has been sitting at the bedside. What is the correct action by the nurse?

Discard the specimen and re-collect.

The nurse has informed a client about the need for a sputum specimen and have provided a specimen container. Later in the day the client states, "I've been collecting spit in the container all day. Is it enough for the test?" Which action is most appropriate?

Discard the specimen container and re-instruct the client about correct collection technique.

The nurse is performing a nasal swab for a client who has a severe cough. What important step should the nurse take prior to completing the nasal swab procedure?

Don gloves and a face shield.

The nurse has finished collecting a urine specimen from the client's indwelling urinary catheter. What would the nurse do with the collected specimen to prepare it to be sent to the lab?

Empty the urine from the syringe into a specimen cup with a lid.

After removing the closing clamp on a colostomy appliance, what would be the nurse's next step before emptying the appliance?

Fold the end of the pouch upward, like a cuff.

While changing the ostomy appliance of a client with a colostomy, the nurse finds significant bleeding from the area around the stoma. What would be the recommended nursing action after notifying the health care provider?

Gently pat the area dry and apply the new appliance when the skin is completely dry.

When changing a client's ostomy appliance, the nurse finds that feces continue to flow from the stoma, making applying the new appliance difficult. What would be the recommended action when this occurs?

Place a piece of gauze over the stoma to absorb the drainage.

The nurse needs to collect a stool specimen for culture from a client with a colostomy. What is the proper procedure for the nurse?

Remove the current bag, collect stool sample, and replace with new bag.

Which situation would require the nurse to contact the health care provider when changing an ostomy appliance? a) Stoma protrudes into the bag. b) Fecal matter continues to flow from the stoma. c) Small amount of bleeding from the stoma. d) Stoma appears brown in color.

Stoma appears brown in color.

A nurse has received a prescription to obtain a specimen for an occult blood test in a client who is being assessed for colon cancer. Which type of sample should the nurse obtain from the client?

Stool

The nurse has taught a client how to change the ostomy bag. How would the clamp be placed to demonstrate that the client understood the directions? a) The curve of the clamp would curve away from the client's body. b) The clamp is straight and would be perpendicular to the client's body. c) The curve of the clamp would follow the curve of the client's body. d) The clamp is straight and would be horizontal to the client's body.

The curve of the clamp would follow the curve of the client's body.

When collecting a urine sample from the port of the client's catheter drainage tubing, the nurse inserts the syringe into the aspiration port, slowly aspirates enough urine for the specimen, and removes the syringe. What would be the nurse's next step?

Unclamp the drainage tubing.

The nurse clamps the catheter drainage tubing to collect a urine specimen from a client's indwelling urinary catheter. How long can the nurse leave the tubing clamped to obtain a sufficient amount of urine?

Up to 30 minutes.

The nurse would like to minimize the time between appliance removal and replacement in the future. What is the best way to reduce time between appliance removal and replacement?

Use the measurements from the current appliance to mark the opening for future appliance changes.

The nurse is teaching a client how to collect a midstream urine sample. After the client has cleaned the perineal area or penis, what instruction would the nurse give to the client?

Void a small amount of urine into the toilet, bedpan, or commode prior to collecting the sample.

When obtaining a urine specimen from an indwelling urinary catheter, how would the nurse clean the aspiration port?

With an alcohol wipe.

The nurse needs to collect stool for occult blood testing from an 8-month-old client. The parent asks if the specimen for testing can be collected from the child's diaper. What is the best response by the nurse? a) "Only if the stool has not been contaminated by urine." b) "It depends on which testing developer is used." c) "Stool cannot be collect from a child's diaper." d) "Stool can be collected only from a cloth diaper."

a) "Only if the stool has not been contaminated by urine."

A nurse is giving instructions to a client on the proper method for providing a stool sample. Which should the nurse tell the client? a) "Void first in the toilet and then catch the stool in a plastic receptacle." b) "Void and defecate in the same plastic receptacle so that both urine and stool samples may be obtained." c) "Set the sample aside in a safe place, and I'll collect it the next time I check on you." d) "Wipe thoroughly and place the toilet paper with the stool."

a) "Void first in the toilet and then catch the stool in a plastic receptacle."

The nurse is preparing to obtain a stool specimen for ova and parasites culture. Which actions are correct? Select all that apply. Include flecks of barium, if visible, in the specimen. a) Collect 15 to 30 mL of liquid stool. b) Obtain the sample immediately after the client has a bowel movement. c) Use a specimen container with preservatives. d) Refrigerate the sample until it can be transported to the laboratory. e) Include visible blood, mucus, or pus in the specimen.

a) Collect 15 to 30 mL of liquid stool. b) Obtain the sample immediately after the client has a bowel movement. c) Use a specimen container with preservatives. e) Include visible blood, mucus, or pus in the specimen.

The nurse is caring for a client with an abdominal wound and prescriptions from the health care provider. Which prescription will the nurse initiate first? a) Obtain a sterile wound culture b) Give ciprofloxacin 1gram IV every 12 hours c) Consult dietician to assist client with meal choices d) Assist client up to chair three times daily

a) Obtain a sterile wound culture

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply. a) Place the swab in the culture tube when done. b) Use the same swab for both wound sites. c) Press and rotate the swab several times over the wound surfaces. d) Insert a swab into the wound. e) Tap the outside of the culture tube with the swab before placing it in the tube. f) Touch the swab to the intact skin at the wound edges.

a) Place the swab in the culture tube when done. d) Insert a swab into the wound. c) Press and rotate the swab several times over the wound surfaces.

The nurse needs to collect a stool specimen for culture from a client. The client passed stool into the toilet instead of using the collection container. What is the next step for the nurse? a) Reinstruct the client on use of collection container for next bowel movement. b) Administer a PRN dose of laxative to the client to collect new sample. c) Collect stool and send to laboratory for culture per regular protocol. d) Inform the client that the culture prescription will now be cancelled.

a) Reinstruct the client on use of collection container for next bowel movement.

The nurse is collecting a wound culture and has removed the current dressing and discarded it. What should the nurse do next? a) Remove gloves and perform hand hygiene. b) Identify the client using two client identifiers. c) Assess and clean the wound per orders. d) Twist and break the seal on the culture tube.

a) Remove gloves and perform hand hygiene.

When collecting a culture from a client's wound, according to evidence-based practice, which type of motion will the nurse use when applying the swab to the wound tissue to obtain the most accurate results? a) Rolling motion b) Back-and-forth motion c) Pushing motion d) Up-and-down motion

a) Rolling motion

The nurse is instructing the client about collection of a sputum specimen. Prior to assisting the client, what things should the nurse review with the client? Select all that apply. a) Sit up straight in bed as fully as possible. b) Spit forcefully into the specimen cup. c) Clear nose and throat before beginning procedure. d) Make sure not to rinse mouth with water prior to procedure. e) Inhale deeply two or three times before trying to obtain specimen.

a) Sit up straight in bed as fully as possible. c) Clear nose and throat before beginning procedure. e) Inhale deeply two or three times before trying to obtain specimen.

The nurse has presented an educational inservice about caring for clients who have newly created ostomies. The nurse asks participants, "How will you know when a client begins to accept the altered body image?" Which responses by participants indicate a correct understanding of the material? Select all that apply. a) "The client uses spray deodorant several times an hour to mask odor." b) "The client makes neutral or positive statements about the ostomy." c) "The client is willing to look at the stoma." d) "The client agrees to take prescribed antidepressants." e) "The client expresses interest in learning self-care."

b) "The client makes neutral or positive statements about the ostomy." c) "The client is willing to look at the stoma." e) "The client expresses interest in learning self-care."

The nurse is reviewing a urinalysis laboratory report of a client. The nurse notes there are nitrates and white blood cells present in the urine. Based on these results, what intervention(s) would be necessary? Select all that apply. a) Prepare to obtain a midstream specimen. b) Prepare to obtain a specimen by catheterization. c) Prepare to obtain a urine culture. d) Notify the health care provider. e) Obtain another voided specimen for comparison.

b) Prepare to obtain a specimen by catheterization. c) Prepare to obtain a urine culture. d) Notify the health care provider.

The nurse is collecting supplies to change the ostomy appliance of a client who has an ileostomy following surgery for a tumor. What items would the nurse prepare to wash around the stoma?

basin of warm water

The nurse is caring for a client prior to surgery. The surgeon has prescribed a preoperative nasal swab for the client for Staphylococcus aureus. In addition to the nasal mucosa, Staphylococcus aureus can also be colonized in what other areas of the body? Select all that apply. a) Eyelids b) Fingernails c) Hairline d) Perineum e) Naval

c) Hairline d) Perineum e) Naval

The charge nurse is observing a new nurse collect a stool sample to determine the presence of occult blood. Which action by the new nurse would require intervention by the charge nurse? a) Obtaining samples from two different areas of the stool b) Using a nonsterile wooden applicator to collect the stool c) Placing two drops of developer directly onto the stool sample d) Applying a small smear of stool onto each window of the test card

c) Placing two drops of developer directly onto the stool sample

A nurse is performing a nasal swab of a client to aid in the diagnosis of an infectious respiratory tract disease. Which actions should the nurse take? Select all that apply. a) Swab the second naris using a new swab. b) Remove the swab immediately after performing the rotations. c) Rotate the swab against the anterior nasal mucosa five times. d) Insert the swab 2 cm into one naris. e) Moisten the swab with sterile water. f) Lightly squeeze the bottom of the collection tube to break the seal on the culture medium.

c) Rotate the swab against the anterior nasal mucosa five times. d) Insert the swab 2 cm into one naris. e) Moisten the swab with sterile water. f) Lightly squeeze the bottom of the collection tube to break the seal on the culture medium.

The nurse is talking with a client whose colostomy pouch frequently comes loose and fall offs. Which interventions are appropriate suggestions? Select all that apply. a) After applying the ostomy pouch, lie flat in the prone position for 10 to 15 minutes to facilitate adhesion. b) Leave the ostomy pouch off and cover the stoma with an adult incontinence pad. c) Secure the ostomy pouch in place by wrapping an elastic bandage around the abdomen, making sure to cover the entire ostomy appliance. d) Apply a commercially available skin barrier before applying the ostomy pouch. e) Thoroughly cleanse the skin surrounding the stoma and allow it to dry completely before applying the ostomy pouch.

d) Apply a commercially available skin barrier before applying the ostomy pouch. e) Thoroughly cleanse the skin surrounding the stoma and allow it to dry completely before applying the ostomy pouch.

The nurse is collecting a wound culture from a client's puncture wound. What is the nurse's first step in the procedure? a) Obtain the wound culture. b) Dress the wound. c) Document the procedure. d) Clean the wound.

d) Clean the wound.

The nurse is obtaining a wound culture and has removed the old dressing and discarded it, performed hand hygiene and applied fresh gloves. What should the nurse do next? a) Assess the drainage for amount, type, color, and odor. b) Open the culture tube and apply the swab to the wound bed. c) Dry the wound bed using a sterile sponge. d) Cleanse the wound with a nonantimicrobial cleanser.

d) Cleanse the wound with a nonantimicrobial cleanser.

The nurse has placed a urine collection bag on an infant. How often should the nurse check the bag to see if the infant has voided?

every 15 minutes

The nurse is emptying an ostomy appliance for a client on bed rest. In what position would the nurse place the client for this procedure?

sitting

The nurse must perform a nasopharyngeal swab for a client. The client asks how he or she should hold the head to make the procedure more comfortable. The nurse instructs the client to place the head in what position?

tipped backward

The nurse is teaching a client about emptying an ostomy appliance. How would the nurse instruct the client to hold the appliance when removing the closing clamp?

upward

The nurse is teaching a client how to empty an ostomy appliance. How often would the nurse recommend the appliance be emptied?

when bag is one-third to one-half full