Nursing Procedures and Specimen Collection Notes
Fingerstick Glucose Level
- When obtaining a blood sample for a fingerstick glucose level on a diabetic client, the most important step is to place the lancet firmly against the side of the fingertip.
24-Hour Urine Collection
- If a 24-hour urine collection is accidentally contaminated after 22 hours, the first nursing action is to contact the physician to inform them about the contamination.
- Before administering contrast media, the nurse will assess the client for allergies to iodine or shellfish.
Throat Culture Technique
- The correct technique for cleaning a specimen for a throat culture is to use a sterile applicator and swab the uvula, tonsil area, and pharynx.
Sterile Urine Specimen Collection
- A nurse can obtain a sterile urine specimen by two methods:
- Straight urine catheterization into the bladder.
- Removing urine from the port of an indwelling catheter.
Clean Catch Urine Specimen
- To prevent contamination when collecting a clean-catch urine specimen, ensure the perineum is cleansed prior to obtaining the sample.
Blood Glucose Specimen Collection
- The process for collecting a blood specimen for measuring blood glucose levels involves holding the selected arm at the side for 30 seconds and collecting the specimen from the side of the finger.
24-Hour Urine Specimen Collection - Initial Void
- When collecting a 24-hour urine specimen, the nurse will have the client void when starting the collection; the first specimen is collected and discarded.
- For a client requiring a stool test for occult blood, apply a small amount of stool in the first and second box to obtain accurate results.
Urinary Catheterization and Privacy
- When preparing to perform a urinary catheterization to obtain a urine specimen, if the nurse is concerned about the client's privacy, they should close the door and cover the client during the procedure.
Urine Culture and Sensitivity via Straight Catheter
- When obtaining a urine specimen for culture and sensitivity via a straight catheter, the nurse should use a sterile specimen container.
Barium Swallow Teaching
- A nurse is reinforcing teaching for a client scheduled for a barium swallow to evaluate dysphagia. The client understands the instructions if they state, "I will drink plenty of fluids after the test."
Laxative After Barium Swallow
- A client scheduled for a barium swallow asks why a laxative is necessary following the procedure. The nurse should respond that it helps eliminate the barium.
Bone Marrow Aspiration and Biopsy Site
- A nurse is reinforcing teaching with a client who is to have a bone marrow aspiration and biopsy. The nurse should inform the client that, in addition to the iliac crest, a common site for this procedure is the sternum.
Post-Upper Endoscopy Monitoring
- A nurse assisting with the plan of care for a client who had an upper endoscopy 1 hour ago should prioritize monitoring the gag reflex.
MRI Teaching
- When preparing a client for magnetic resonance imaging (MRI), the nurse should include the instruction, "You'll have to remove metal objects such as watches and body jewelry."
MRI of the Heart and Great Vessels
- A nurse is reinforcing teaching with a client scheduled for a magnetic resonance imaging (MRI) of the heart and great vessels. The instruction should include, "You will need to remove metal objects such as jewelry."
Abdominal Paracentesis Preparation
- A nurse preparing a client who has advanced cirrhosis for an abdominal paracentesis should instruct the patient to empty the bladder.
Thoracentesis Positioning
- A nurse caring for a client scheduled to undergo thoracentesis should place the client in a sitting position, leaning forward over the bedside table for the procedure.
Glucometer Use Teaching
- A nurse is reinforcing teaching with a client who has diabetes mellitus about using a glucometer. The client shows understanding if they use the side of the fingertip as the puncture site.
Occult Blood Detection
- If a health care provider has ordered a stool specimen for blood that is not possible to see with the naked eye, the exam detects occult blood.
Abnormal Urine Sample Finding
- In the assessment of a patient's urine sample, bloody mucus would be considered an abnormal finding.
Sputum Sample Collection Timing
- It is best to collect a sputum sample from a patient in the morning, upon awakening.
Bone Marrow Biopsy Comfort
- A nurse caring for a client scheduled for a bone marrow biopsy, who expresses fear about the procedure, should respond, "The biopsy can be uncomfortable, but we will try to keep you as comfortable as possible."
Chest X-Ray Teaching
- A nurse caring for a client who is to have a chest x-ray should reinforce that front, back, and side views of the chest will be taken during the test.
Post-Lumbar Puncture Care
- A nurse caring for a client following a lumbar puncture should:
- Provide oral fluids.
- Monitor for nausea.
- Check level of consciousness.
- Check sensation in the toes.
Post-Thoracentesis Complication
- A nurse monitoring a client who has just had a thoracentesis should notify the provider immediately if the client experiences increased heart rate, as it indicates a complication.
Urinalysis Results to Report
- A nurse reviewing the urinalysis results of a client who reports urinary frequency and burning should report microscopic hematuria to the provider.
Midstream Urine Specimen Collection Instruction
- A charge nurse should intervene if a newly licensed nurse instructs a female client to cleanse the area for a midstream urine specimen by moving in a back-and-forth motion. The correct method involves moving front to back to avoid contamination.
- The nurse should respond by stating that the stool guaiac is testing for blood in the client's feces.
- The nurse providing care for a client that requires a stool test for occult blood should apply a small amount of stool on the first and second box to obtain the most accurate results.
Barium Swallow Teaching - Fluids
- A nurse is reinforcing teaching a client who is scheduled for a barium swallow to evaluate dysphagia. Which of the following statements should indicate to the nurse that the client understands the instructions? "I will drink plenty of fluids after the test."