The nurse is obtaining a throat culture. Which action indicates correct technique?
1. Inserting the swab into the sterile tube without touching the outside of the container
2. Inserting a tongue blade to depress the anterior two-thirds of the tongue
3. Swabbing along the side of the cheek inside the mouth
4. Swabbing the pharynx gently and quickly, avoiding the tonsils
Correct Answer: 1
The nurse inserts a tongue blade to depress the anterior third of the tongue, not two-thirds. The swab is inserted without touching the mouth or tongue, and swabs along the tonsils, making sure to contact any areas on the pharynx that are particularly erythematous, or contain exudate. The swab is removed and placed into the container without touching the outside.
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While caring for an elderly client, the nurse notices the client is exhibiting increased episodes of forgetfulness, restlessness, and increased anxiety. Which assessment data is most significant for this client?
A) Age at retirement B) Hobbies and activities C) Recent loss of spouse D) Ability to care for own ADLs
The nurse would explain to a client who smokes that the nicotine in cigarette smoke increases the prevalence of CHD by
a. causing proliferation of smooth muscle cells. b. decreasing the oxygen-carrying capacity of the blood. c. increasing fat deposits along the intima of blood vessels. d. increasing the heart rate and the risk of dysrhythmia.
A group member has taken on the role of the "gatekeeper." Which of the following actions would most likely be taken by this member?
a. Seek and accept the authority or direction of others b. Guide and direct the group activity c. Control outsiders' access to the group d. Focus the movement toward the main work of the group
The nurse is working with an adolescent mother and her newborn. As the nurse begins to gather the supplies needed to bathe the infant, the adolescent tells the nurse, "I'm really scared that I won't take care of my baby correctly
My mother says I'll probably hurt the baby because I'm too young to be a mother." The best response by the nurse is: 1. "You are very young, and parenting will be a challenge for you." 2. "Your mother was probably right. Be very careful with your baby." 3. "Mothers have instincts that kick in when they get their babies home." 4. "We can give the baby's bath together. I'll help you learn how to do it."