Chapter 43: Specimen Collection Nursing School Test Banks

MULTIPLE CHOICE

1. How should the nurse identify a patient before obtaining a laboratory specimen from him?

a.

Use at least two patient identifiers.

b.

Look at the chart before entering the room.

c.

Ask the patient his name.

d.

Check the patients armband twice.

ANS: A

Before obtaining a laboratory specimen, use at least two identifiers such as checking the identification number on the admission armband and asking the patients name. Patients who are confused or who have a language barrier may smile and not understand the question. The patient could also have the wrong armband on; checking it twice would not change that.

DIF: Cognitive Level: Application REF: Text reference: p. 1055

OBJ: Identify measures to minimize anxiety and promote safety for selected techniques.

TOP: Positive Patient Identification KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2. When discussing the collection of a clean-voided urine specimen, it is important for the nurse to instruct the patient to:

a.

use a clean specimen cup.

b.

collect 100 to 150 mL of urine for testing.

c.

void some urine first and then collect the sample.

d.

wash the perineal area with soap and water immediately before voiding.

ANS: C

After the patient has initiated a urine stream, pass the urine specimen container into the stream and collect 90 to 120 mL of urine. A sterile specimen container is used. Pour antiseptic solution over cotton balls. A cotton ball or gauze is used to cleanse the perineum.

DIF: Cognitive Level: Application REF: Text reference: p. 1056

OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens.

TOP: Obtaining Urine Culture and Sensitivity (C&S) Specimen

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. The nurse needs to obtain a sterile urine specimen for culture and sensitivity (C&S) from a patient who has an indwelling catheter. The catheter was placed the night before. What must the nurse do to obtain the specimen?

a.

Obtain the urine from the drainage bag.

b.

Clamp the drainage tubing for 10 to 15 minutes.

c.

Draw urine using a 20-mL syringe.

d.

Insert the needle into the silicone catheter.

ANS: B

Clamp the drainage tubing with a clamp or rubber band for 30 minutes to permit collection of fresh, sterile urine in the catheter tubing rather than draining into the bag. Do not collect a urine specimen for culture tests from a urine drainage bag unless it is the first urine to drain into a new sterile bag. Draw urine into a 3-mL syringe (for culture), or draw urine into a 20 mL-syringe (for routine urinalysis). Proper volume is needed to perform the test. Do not puncture Silastic, silicone, or plastic catheters. These are not self-sealing.

DIF: Cognitive Level: Application REF: Text reference: p. 1057

OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens.

TOP: Obtaining Urine C&S Specimen From a Catheter

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. What should the nurse do first if a patient is unable to void on demand for a clean-voided specimen?

a.

Perform Creds procedure for the suprapubic area.

b.

Catheterize the patient to obtain the specimen.

c.

Offer fluids, if allowed, and wait about 30 minutes.

d.

Notify the physician that the test cannot be completed.

ANS: C

If the patient is unable to urinate on demand, offer fluids if permitted. Allow more time for urine to accumulate in the bladder. Try obtaining a specimen after 30 minutes. If the patient has no urine in the bladder, Creds would not be useful. The risk for infection precludes the use of catheterization simply to obtain a specimen. If the patient is unable to void after several hours, the physician may need to be called to obtain an order for catheterization.

DIF: Cognitive Level: Application REF: Text reference: p. 1058

OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens.

TOP: Obtaining Urine C&S Specimen From a Catheter

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5. What must the nurse do to collect a midstream urine sample from an infant?

a.

Apply a sterile plastic collection bag to the perineum.

b.

Wring out diapers and collect the urine in a specimen container.

c.

Have the infant sit facing the back of the toilet.

d.

Catheterize the infant and collect the urine using sterile procedure.

ANS: A

Use a sterile plastic urine collecting bag that adheres to the perineum of a nontoilet-trained child. Special considerations for boys: Place the penis and scrotum inside the bag. Diapers may be contaminated. Seating on a toilet generally is not realistic for an infant. Catheterization should be used as a last resort only.

DIF: Cognitive Level: Application REF: Text reference: p. 1058

OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens.

TOP: Obtaining Urine C&S Specimen From an Infant

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

6. What should the nurse do when a patient is required to provide a timed urine specimen?

a.

Save all urine from the time the test began.

b.

Leave the collection bottle on the floor near the patients bed.

c.

Send notices along with the patient when leaving the unit to have all urine saved and returned to the unit.

d.

Remove contaminants such as toilet paper from the urine before transferring it to the collection bottle.

ANS: C

Place signs on the patients door and toileting area, indicating that a timed urine specimen collection is in progress. If the patient leaves the unit for a test or procedure, be sure that personnel in that area collect and save all urine. The nurse discards the first specimen and then collects every successive specimen until the time period has ended. Place a specimen collection container in the bathroom and, if indicated, in a pan of ice. The urine specimen is not to be contaminated with feces or toilet tissue.

DIF: Cognitive Level: Application REF: Text reference: p. 1059

OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens.

TOP: Obtaining a Timed Urine Specimen

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7. What instructions does the nurse provide to the patient to obtain a double-voided urine specimen?

a.

Save two separate specimens from the first voiding in the morning.

b.

Add two specimens together from the morning voiding and the evening voiding.

c.

Discard the first sample, then wait a half hour and void again.

d.

Void first and then self-catheterize to obtain the specimens.

ANS: C

A fresh specimen should be used because stagnant urine that has been in the bladder for several hours will not accurately reflect the serum glucose level at the time of testing. Ask the patient to collect a random urine specimen and discard, drink a glass of water, and collect another specimen 30 to 45 minutes later.

DIF: Cognitive Level: Application REF: Text reference: p. 1060

OBJ: Identify special conditions necessary for collection of each specimen.

TOP: Collecting a Double-Voided Specimen

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8. An appropriate procedure for urine testing with reagent strips for chemical properties of the sample is to:

a.

obtain the first voided specimen in the morning.

b.

immerse the test strip in the urine and remove immediately.

c.

add a chemically active tablet to the urine and then test it with a reagent strip.

d.

wipe the strip with a sterile gauze after dipping.

ANS: B

Immerse the strip briefly in the urine sample, and then remove it and tap it gently on the side of the container; prolonged exposure to excess urine can dilute reagents. Stagnant urine stored in the bladder overnight or for long periods does not reveal quantities of glucose and ketones excreted by the kidney at the time of testing. Kits that contain tablets do not also use strips; the tablet contains the reagent and changes color to indicate chemical properties of the urine. Tap the strip gently against the side of the container to shed excess urine; do not wipe it.

DIF: Cognitive Level: Application REF: Text reference: p. 1060

OBJ: Discuss nursing responsibilities for processing a specimen after collection.

TOP: Testing the Chemical Properties of Urine

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

9. A patient is concerned because her first guaiac test is positive. What information should the nurse share with the patient?

a.

The patient probably has colorectal cancer.

b.

The test needs to be repeated after she eats some red meat.

c.

The test needs to be repeated at least 3 times.

d.

The patient needs a low-residue diet to reduce intestinal abrasions.

ANS: C

A single positive test result does not confirm bleeding or indicate colorectal cancer. For confirmed positive results, the test must be repeated at least 3 times while the patient is on a meat-free, high-residue diet. More in-depth diagnosis is needed with a positive result.

DIF: Cognitive Level: Application REF: Text reference: p. 1061

OBJ: Explain instructions to encourage patient cooperation for successful collection of each specimen. TOP: Guaiac Testing

KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity

10. When teaching a patient about home testing for occult blood, the nurse instructs the patient that:

a.

positive results are indicative of bleeding.

b.

poultry and fish should be eaten before testing.

c.

testing should be done carefully during the menstrual cycle.

d.

two samples should be obtained from the same part of the stool specimen.

ANS: C

Specimens will be positive if contaminated by menstrual blood or hemorrhoidal blood or povidone-iodine. A single positive test result does not confirm bleeding or indicate colorectal cancer. Diets rich in meats; green, leafy vegetables; poultry; and fish may produce false-positive results. Obtain a second fecal specimen from a different portion of the stool.

DIF: Cognitive Level: Application REF: Text reference: p. 1061

OBJ: Explain instructions to encourage patient cooperation for successful collection of each specimen. TOP: Guaiac Testing

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

11. A patient asks what food may be eaten before a stool specimen is obtained for occult blood. What food should the nurse allow the patient to eat?

a.

Fish

b.

Apples

c.

Red meats

d.

Green, leafy vegetables

ANS: B

Diets rich in meats; green, leafy vegetables; poultry; and fish may produce false-positive results.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 1061

OBJ: Explain instructions to encourage patient cooperation for successful collection of each specimen. TOP: Guaiac Testing

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

12. The nurse evaluates that an expected outcome for analysis of gastric secretions is:

a.

inability of the patient to discuss the rationale for the test.

b.

negative occult blood.

c.

the presence of clumps or clots.

d.

the presence of brown, coffee-ground secretions.

ANS: B

An expected outcome after completion of the procedure is the test for occult blood. If frank red blood is observed or coffee-ground materials are seen, report these findings immediately. This is an unexpected finding.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 1064

OBJ: Explain the rationale for the collection of each specimen.

TOP: Guaiac Testing of Gastric Contents

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

13. An appropriate technique for the nurse to implement when obtaining throat cultures is to:

a.

have the patient lie flat in the bed.

b.

do the culture before meals or an hour after meals.

c.

avoid touching the swab to any of the inflamed areas.

d.

place pressure on the tongue blade along the back of the tongue.

ANS: B

Plan to do the culture before mealtime or at least 1 hour after eating. This procedure often induces gagging; timing will decrease the patients chances of vomiting. Ask the patient to sit erect in bed or on a chair facing the nurse. Gently but quickly swab the tonsillar area from side to side, making contact with inflamed or purulent sites. Depress the anterior third of the tongue only; placement of a tongue blade along the back of the tongue is more likely to initiate a gag reflex.

DIF: Cognitive Level: Application REF: Text reference: p. 1065

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Obtaining a Throat Culture KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

14. What step should the nurse take to obtain a vaginal specimen for a culture?

a.

Apply sterile gloves.

b.

Assist the patient to a side-lying position.

c.

Collect discharge from the perineum on the same swab.

d.

Insert the swab to 1 inch into the orifice and rotate before removal.

ANS: D

Gently insert the swab to 1 inch into the vaginal orifice and rotate before removal. Apply clean disposable gloves. The patient should be in dorsal recumbent position. If a discharge near the vagina appears different from the discharge along the perineum, collect separate specimens from each area.

DIF: Cognitive Level: Application REF: Text reference: p. 1070

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Obtaining a Vaginal Culture KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

15. When using a commercially prepared tube to collect a culture, the nurse should:

a.

take the swab and mix it in the reagent to check for color changes.

b.

place the swab into the culture tube and then add a special reagent to the tube.

c.

crush the ampule at the end of the tube and put the tip of the swab into the solution.

d.

place the swab into the tube, close it securely, and keep it warm until it is sent to the laboratory.

ANS: C

Immediately squeeze the end of the tube to crush the ampule, and push the tip of the swab into fluid medium.

DIF: Cognitive Level: Application REF: Text reference: p. 1070

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Preparing a Culture Tube KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

16. A nurse suspects that the patient may have tuberculosis. She sends a sputum sample to the lab for testing. When the following tests are compared, which will best support the diagnosis of possible tuberculosis?

a.

Acid-fast bacilli

b.

General cytology

c.

Chemical analysis

d.

Culture and sensitivity

ANS: A

Sputum specimens are collected to identify cancer cells, for culture and sensitivity (C&S) to identify pathogens and determine the antibiotics to which they are sensitive, and for acid-fast bacilli to diagnose pulmonary tuberculosis. Cytological or cellular examinations of sputum may identify aberrant cells or cancer. Chemical analysis would indicate chemicals within the blood, not sputum. Sputum collected for culture and sensitivity testing is used to identify specific microorganisms and to determine which antibiotics are most sensitive. A definitive diagnosis of TB also requires a sputum culture and sensitivity.

DIF: Cognitive Level: Analysis REF: Text reference: p. 1071

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Acid-Fast Bacilli KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

17. The patient has come to the emergency department complaining of coughing up bloody sputum. The patient has a 30-year history of smoking and has lost 15 pounds in the last month. What will the nurse expect the sputum specimen to be evaluated for?

a.

Culture and sensitivity

b.

AFB

c.

Cytology

d.

Chemical analysis

ANS: C

The patient is showing signs of cancer. Sputum specimens are collected to identify cancer cells.

Sputum collected for culture and sensitivity testing is used to identify specific microorganisms. The AFB is used to support the diagnosis of tuberculosis. Chemical analysis would indicate chemicals within the blood, not sputum.

DIF: Cognitive Level: Analysis REF: Text reference: p. 1071

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Cytological Examination of Sputum

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

18. An appropriate technique that the nurse can tell the patient to implement before obtaining a sputum specimen is to:

a.

use mouthwash before the collection.

b.

splint the surgical incision before coughing.

c.

try to obtain a sample immediately after eating.

d.

take a deep breath, cough hard, and expectorate.

ANS: B

If the patient has a surgical incision or localized area of discomfort, have the patient place hands firmly over the affected area, or place a pillow over the area. Splinting of painful areas minimizes muscular stretching and discomfort during coughing and thus makes cough more productive. The patient should not use mouthwash or toothpaste because it may decrease viability of microorganisms and culture results. Have the patient wait 1 to 2 hours after eating. After a series of deep breaths, ask the patient to cough after full inhalation.

DIF: Cognitive Level: Application REF: Text reference: p. 1072

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Obtaining Sputum Specimen KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

19. During a sputum collection, the patient becomes hypoxic. What action should the nurse take?

a.

Suction the patient thoroughly.

b.

Continue to complete the procedure quickly.

c.

Stop the procedure and provide oxygen, if ordered.

d.

Have the patient lie down and take deep breaths before continuing with the specimen collection.

ANS: C

If the patient becomes hypoxic, discontinue the procedure until stable and provide oxygen therapy as needed, if ordered. Suctioning can decrease usable oxygen to the patient.

DIF: Cognitive Level: Application REF: Text reference: p. 1074

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Hypoxia During Suctioning KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

20. The nurse has delegated ADL care of a patient with a large wound that is draining. Which of the follow should the nurse instruct the nurse assistant to report back to her?

a.

The wound has a foul odor.

b.

Drainage is decreased.

c.

The patients temperature is slightly below normal.

d.

The patient does not complain of discomfort.

ANS: A

Report a foul odor, increased drainage, and increased temperature or complaints of discomfort.

DIF: Cognitive Level: Application REF: Text reference: p. 1075

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Signs of Infection KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

21. An appropriate technique for the nurse to use when culturing wound drainage that is suspected to contain anaerobic bacteria is to:

a.

use older secretions for the specimen.

b.

add exudate from the skin to the wound specimen.

c.

aspirate 5 to 10 mL of exudate from a deep cavity wound.

d.

swab carefully and slowly in a back-and-forth motion across the wound.

ANS: C

Take a swab from a special anaerobic culture tube, swab deeply into the draining body cavity, and rotate gently. Remove the swab and return it to the culture tube, or insert the tip of a syringe into the tube, and aspirate 5 to 10 mL of exudate. Cleanse the area around the wound edges with an antiseptic swab. This removes old exudate and skin flora, preventing possible contamination of the specimen. Never collect exudate from the skin unless it is a separate culture and is labeled as such.

DIF: Cognitive Level: Application REF: Text reference: p. 1076

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Obtaining Anaerobic Wound Specimen

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

22. The patient is diagnosed with suspected bacteremia. The physician has ordered blood cultures from two different sites. The patient is complaining of chills and has an elevated temperature. What action should the nurse take in the presence of these symptoms?

a.

Delay drawing the blood cultures until symptoms subside.

b.

Draw blood from only one site to prevent further discomfort.

c.

Draw the blood cultures as ordered.

d.

Draw blood from the patients intravenous (IV) catheter.

ANS: C

Because bacteremia may be accompanied by fever and chills, blood cultures should be drawn when the patient is experiencing these clinical signs. It is important that at least two culture specimens be drawn from two different sites. Bacteremia exists when both cultures grow the infectious agent. Because blood culture specimens obtained from an IV catheter are frequently contaminated, tests that use them should not be performed unless catheter sepsis is suspected.

DIF: Cognitive Level: Application REF: Text reference: p. 1078

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Drawing Blood Cultures KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

23. When blood specimens are drawn, which of the following is true?

a.

Draw cryoglobulin levels using test tubes placed on ice.

b.

To test ammonia and ionized calcium levels, warm the test tubes.

c.

To draw for lactic acid levels, do not use a tourniquet.

d.

To draw for vitamin levels, use light to determine density.

ANS: C

Some specimens have special collection requirements before or after specimen collection, for example, for lactic acid levels, do not use a tourniquet. For cryoglobulin levels, use pre-warmed test tubes. For ammonia and ionized calcium levels, place the tube in ice for delivery to the laboratory. For vitamin levels, avoid exposure of the test tube to light.

DIF: Cognitive Level: Analysis REF: Text reference: p. 1079

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Drawing Blood KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

24. A patient is to have a venipuncture to obtain a blood sample to check ammonia levels. What should the nurse do when given this information?

a.

Use pre-warmed test tubes.

b.

Keep the specimen out of the light.

c.

Avoid use of a tourniquet during the procedure.

d.

Place the samples on ice before sending them to the lab.

ANS: D

Some specimens have special collection requirements before or after specimen collection. For ammonia levels, tubes must be placed on ice for delivery to the laboratory. For cryoglobulin levels, use pre-warmed test tubes. For vitamin levels, avoid exposure of the test tube to light. For lactic acid levels, do not use a tourniquet.

DIF: Cognitive Level: Analysis REF: Text reference: p. 1079

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Drawing Blood KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

25. The nurse is preparing to perform a venipuncture on a patient. Which of the following is an appropriate action for the nurse to take?

a.

Apply the tourniquet until the distal pulse is no longer felt.

b.

Remove the tourniquet after 1 minute.

c.

Instruct the patient to vigorously open and close the fist.

d.

Do not use veins that rebound.

ANS: B

Do not keep a tourniquet on the patient longer than 1 minute. Prolonged tourniquet application causes stasis, localized acidemia, and hemoconcentration. Palpate the distal pulse (e.g., brachial) below the tourniquet. If the pulse is not palpable, reapply the tourniquet more loosely. Ask the patient to open and close the fist several times, finally leaving the fist clenched. Instruct the patient to avoid vigorous opening and closing of the fist. Palpate for a firm vein that rebounds; a patent, healthy vein is elastic and rebounds on palpation.

DIF: Cognitive Level: Application REF: Text reference: p. 1079

OBJ: Use correct technique to perform venipuncture. TOP: Applying Tourniquet

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

26. An appropriate technique for the nurse to implement when preparing for a venipuncture is to:

a.

tie the tourniquet in a knot.

b.

tie the tourniquet so it can be easily removed.

c.

place the tourniquet 6 to 8 inches above the selected site.

d.

make the tourniquet tight enough to occlude the distal pulse.

ANS: B

Apply the tourniquet by encircling the extremity and pulling one end of the tourniquet tightly over the other, looping one end under the other so it can be removed by pulling the end with a single motion. Apply the tourniquet 2 to 4 inches above the venipuncture site selected. Palpate the distal pulse below the tourniquet; if the pulse is not palpable, reapply the tourniquet more loosely.

DIF: Cognitive Level: Application REF: Text reference: p. 1079

OBJ: Use correct technique to perform venipuncture. TOP: Applying Tourniquet

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

27. The nurse is drawing blood from a patient to determine the blood alcohol level. Which step is an appropriate action for the nurse to take?

a.

Swab the area with an antiseptic swab.

b.

Swab the area with an alcohol swab.

c.

Do not swab the area at all.

d.

Apply the tourniquet for 5 minutes.

ANS: A

If drawing a sample for a blood alcohol level or blood culture, use only an antiseptic swab, not an alcohol swab. Do not keep a tourniquet on the patient longer than 1 minute.

DIF: Cognitive Level: Application REF: Text reference: p. 1080

OBJ: Use correct technique to perform venipuncture.

TOP: Drawing Blood for Blood Alcohol Level

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

28. When performing a venipuncture, the nurse should:

a.

inject with the needle at a 45-degree angle.

b.

select a vein that is rigid and cordlike, and that rolls when palpated.

c.

perform the needle insertion immediately after cleansing the skin with alcohol.

d.

place the thumb of the nondominant hand about 1 inch below the site and pull the skin taut.

ANS: D

Place the thumb or forefinger of the nondominant hand 1 inch below the site and gently pull the skin taut. Stretch the skin down until the vein is stabilized. Hold a syringe and needle at a 15- to 30-degree angle from the patients arm with the bevel up. Palpate for a firm vein that rebounds. Do not use veins that feel rigid or cordlike; a thrombosed vein is rigid, rolls easily, and is difficult to puncture. Allowing alcohol to dry completes its antimicrobial task and reduces the sting of venipuncture. Alcohol left on the skin can cause hemolysis of the sample.

DIF: Cognitive Level: Application REF: Text reference: p. 1081

OBJ: Use correct technique to perform venipuncture. TOP: Venipuncture

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

29. When obtaining a venipuncture sample for a blood culture, the nurse should:

a.

recap the needles.

b.

shake the culture bottles well.

c.

use two different sites to draw samples.

d.

inoculate the aerobic culture bottle first.

ANS: C

Collect 10 to 15 mL of venous blood by venipuncture in a 20-mL syringe from each venipuncture site. Culture specimens must be obtained from two sites. Dispose of needles, syringe, and soiled equipment in the proper container. Do not cap the needles. Mix gently after inoculation. If both aerobic and anaerobic cultures are needed, inoculate the anaerobic culture first.

DIF: Cognitive Level: Analysis REF: Text reference: p. 1083

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Blood Cultures KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

30. When teaching about the procedure for capillary puncture, the nurse instructs a patient to:

a.

hold the finger upright.

b.

use the central tip of the finger.

c.

allow the antiseptic to dry completely.

d.

vigorously squeeze the end of the finger.

ANS: C

Clean the site with an antiseptic swab, and allow it to dry completely. Alcohol left on the skin can cause hemolysis of the sample. Hold the finger to be punctured in a dependent position while gently massaging the finger toward the puncture site to increase blood flow to the area before puncture. Select the lateral side of the finger; be sure to avoid the central top of the finger, which has a more dense nerve supply.

DIF: Cognitive Level: Application REF: Text reference: p. 1088

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Capillary Puncture KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

31. Which of the following is the site of choice for obtaining samples for ABG?

a.

Radial artery

b.

Brachial artery

c.

Femoral artery

d.

Popliteal artery

ANS: A

The radial artery is the safest, most accessible site for puncture; it is superficial, is not adjacent to large veins, and usually has adequate collateral circulation by the ulnar artery. Its use is relatively painless if the periosteum is avoided, and it is used when Allens test is positive. The brachial artery has reasonable collateral blood flow but is less superficial, is more difficult to palpate and stabilize, and carries increased risk for venous puncture; its use results in increased discomfort. The femoral artery should not be used by nurses without specialized training. The popliteal artery usually is not used.

DIF: Cognitive Level: Application REF: Text reference: p. 1092

OBJ: Use correct technique to perform arterial puncture for blood gas measurement.

TOP: Arterial Blood Gases KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

32. An appropriate technique for the nurse to implement when obtaining an ABG specimen is to:

a.

insert the needle at a 45-degree angle.

b.

use a 19-gauge, 1-inch needle.

c.

leave 0.5 mL of heparin in the syringe.

d.

aspirate blood after the puncture.

ANS: A

Hold the needle bevel up, and insert the needle at a 45-degree angle into the artery. Use a 23- to 25-gauge needle. Aspirate 0.5 mL sodium heparin into a syringe, and then eject all heparin in the barrel out of the syringe. Allow arterial pulsations to pump 2 to 3 mL of blood into the heparinized syringe slowly to reduce the presence of air bubbles.

DIF: Cognitive Level: Application REF: Text reference: p. 1093

OBJ: Use correct technique to perform arterial puncture for blood gas measurement.

TOP: Arterial Blood Gases KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

33. What should the nurse do after obtaining a sample for ABG?

a.

Maintain pressure over the site for 3 to 5 minutes.

b.

Check the artery proximal to or above the puncture site.

c.

Place the syringe into a plastic bag, and send it to the lab.

d.

Apply a cool compress to hematoma formation at the puncture site.

ANS: A

Maintain continuous pressure on and proximal to the site for 3 to 5 minutes. Palpate the artery below or distal to the puncture site to determine whether pulse quality has changed, indicating alteration in arterial flow. Place a syringe in a cup of crushed ice. Failure to do this may result in decreased pH, arterial oxygen pressure (PaO2), and oxygen saturation. Apply warm compresses to enhance the absorption of blood.

DIF: Cognitive Level: Application REF: Text reference: p. 1094

OBJ: Use correct technique to perform arterial puncture for blood gas measurement.

TOP: Arterial Blood Gases KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. When collecting specimens, the nurse should: (Select all that apply.)

a.

wear gloves and perform hand hygiene.

b.

handle excretions discreetly.

c.

explain the procedure to the patient.

d.

allow patients to collect their own urine specimens.

ANS: A, B, C, D

When collecting specimens, wear gloves, and perform hand hygiene. Also, handle excretions discreetly. Invasive collection procedures and fear of unknown test results often cause patients anxiety. Patients who receive a clear explanation about the purpose of the specimen and how the nurse will obtain it are more cooperative. Give patients proper instruction to collect their own specimens of urine, stool, and sputum, thus avoiding embarrassment.

DIF: Cognitive Level: Application REF: Text reference: p. 1053

OBJ: Identify measures to minimize anxiety and promote safety during specimen collection.

TOP: Specimen Collection KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2. When obtaining laboratory specimens, the nurse needs to be aware that: (Select all that apply.)

a.

specimen collection may cause anxiety and embarrassment.

b.

sociocultural variations may affect a patients compliance.

c.

contact isolation precautions are required for collection of blood.

d.

two identifiers, including room number, must be used.

ANS: A, B

The nurse should recognize that specimen collection may cause anxiety, embarrassment, and/or discomfort. Cultural considerations are important when collecting specimens and performing diagnostic procedures. Culture and beliefs may affect a patients response and willingness to participate in specimen collection. Use of a patients room number is not an acceptable identifier, and the nurse should follow standard precautions when collecting specimens of blood or other body fluids.

DIF: Cognitive Level: Application REF: Text reference: p. 1053

OBJ: Recognize the impact of patient-centered issues on patients cooperation with collection of specimens. TOP: Obtaining Laboratory Specimens

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

3. A timed urine collection can be used for which of the following? (Select all that apply.)

a.

Glucose

b.

Adrenocorticosteroids

c.

Bacteria count

d.

Color

ANS: A, B

Some tests of renal function and urine composition require urine to be collected over 2 to 72 hours. The 24-hour timed collection is most common. These tests measure for elements such as amino acids, creatinine, hormones, glucose, and adrenocorticosteroids, whose levels fluctuate throughout the day. A timed urine collection also can serve as a means to measure the concentration or dilution of urine. Bacteria count and color can be determined through a routine urinalysis.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 1054

OBJ: Use correct technique for collecting clean-voided, timed, and catheterized urine specimens.

TOP: Obtaining a Timed Urine Specimen

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. Hemoccult testing helps to reveal blood that is visually undetectable. This test is a useful diagnostic tool for which of the following conditions? (Select all that apply.)

a.

Colon cancer

b.

Upper gastrointestinal (GI) ulcers

c.

Localized gastric parasites

d.

Large polyps

ANS: A, B, C, D

This test is a useful diagnostic tool for conditions such as colon cancer, upper gastrointestinal ulcers, and localized gastric parasitic infection or intestinal irritation. The amount of bleeding increases with the size of the polyp and the stage of cancer. People with small polyps (less than 1 cm in diameter) bleed scarcely more than those without polyps.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 1061

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Guaiac Testing KEY: Nursing Process Step: Diagnosis

MSC: NCLEX: Physiological Integrity

5. The nurse is caring for a patient who has had a craniotomy. The patient appears to need endotracheal suctioning. The nurse is aware that this can be of concern because suctioning can cause which of the following? (Select all that apply.)

a.

Violent coughing

b.

Aspiration of stomach contents

c.

Increased intracranial pressure

d.

Bradycardia or tachycardia

ANS: A, B, C, D

Sometimes suctioning provokes violent coughing, causes vomiting and aspiration of stomach contents, and induces constriction of pharyngeal, laryngeal, and bronchial muscles. In addition, suctioning may cause hypoxemia or vagal overload, resulting in cardiopulmonary compromise and increased intracranial pressure.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 1074

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Suctioning KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

6. In explaining to the patient about obtaining a sputum specimen to diagnose tuberculosis, the nurse explains which of the following? (Select all that apply.)

a.

Specimens are best obtained in the early morning.

b.

Acid-fast bacilli (AFB) smears require three consecutive morning samples.

c.

Bacteria accumulate as secretions pool.

d.

Specimens should be obtained at bedtime.

ANS: A, B, C

Specimens for AFB require three consecutive morning samples, and cultures can take up to 8 weeks. The ideal time to collect sputum is early morning because bronchial secretions tend to accumulate during the night. Bacteria also accumulate as secretions pool.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 1072

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Cultures for Acid-Fast Bacilli and C&S for Tuberculosis

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

COMPLETION

1. Assessment of the chemical properties of urine is done by immersing a special, chemically prepared strip of paper into a clean urine specimen, or by combining drops of urine with chemically prepared tablets. The _____________ of the strip or tablet indicates the presence of any of unique chemical properties.

ANS:

change in color

You assess the chemical properties of urine by immersing a special, chemically prepared strip of paper into a clean urine specimen, or by combining drops of urine with chemically prepared tablets. The change in color of the strip or tablet indicates the presence of glucose, ketones, protein, and blood as well as pH of the urine.

DIF: Cognitive Level: Application REF: Text reference: p. 1060

OBJ: Discuss nursing responsibilities for processing a specimen after collection.

TOP: Testing the Chemical Properties of Urine

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2. A common test performed on fecal material is the ________ test for fecal occult blood.

ANS:

guaiac

A common test performed on fecal material is the guaiac test for fecal occult blood.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 1061

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Guaiac Testing KEY: Nursing Process Step: Diagnosis

MSC: NCLEX: Physiological Integrity

3. ______________ is often indicated to collect sputum from patients unable to spontaneously produce a sample for laboratory analysis.

ANS:

Suctioning

Suctioning is often indicated to collect sputum from patients unable to spontaneously produce a sample for laboratory analysis.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 1072

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Suctioning KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

4. Localized inflammation, tenderness, warmth at the wound site, and purulent drainage usually signify _______________.

ANS:

wound infection

Localized inflammation, tenderness, warmth at the wound site, and purulent drainage usually signify wound infection.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 1075

OBJ: Properly collect specimens for culture from the nose and throat, urethra and vagina, sputum, and wound. TOP: Wound Infection

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5. _______________ organisms grow in superficial wounds exposed to the air.

ANS:

Aerobic

Aerobic organisms grow in superficial wounds exposed to the air.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 1075

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Aerobic Organisms KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

6. The least traumatic method of obtaining a blood specimen is known as __________.

ANS:

skin puncture

capillary puncture

Skin puncture, also called capillary puncture, is the least traumatic method of obtaining a blood specimen.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 1085

OBJ: Use correct technique for collecting specimens and cultures for blood and other body fluids.

TOP: Skin/Capillary Puncture KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

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