The nurse is preparing to obtain a throat culture. Which observation indicates that the nurse has performed this skill before?
1. The nurse allows the client to insert the swab in the mouth.
2. The nurse removes the swab while making sure to touch the sides of the tonsils.
3. The nurse has the client tilt the head back and say "ah" to relax the tongue to avoid the gagging reflex.
4. The nurse asks the client to blow the nose to clear the nasal passageway and then checks with penlight for patency.
3
Rationale 1: Allowing the client to insert the swab in the mouth is inappropriate and will result in the need to re-swab.
Rationale 2: Touching the sides of the tonsils will contaminate the swab.
Rationale 3: Having the client tilt the head back and say "ah" helps to relax the throat and prevent gagging.
Rationale 4: Asking the client to blow the nose to clear the nasal passageways and then checking with a penlight for patency is the procedure for a nasal specimen.
Global Rationale: Having the client tilt the head back and say "ah" helps to relax the throat and prevent gagging. Allowing the client to insert the swab in the mouth is inappropriate and will result in the need to re-swab. Touching the sides of the tonsils will contaminate the swab. Asking the client to blow the nose to clear the nasal passageways and then checking with a penlight for patency is the procedure for a nasal specimen.
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