NCLEX-PN

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9. The doctor orders a midstream urine specimen for your client, who is an alert, oriented, and ambulatory female client. What element should you include in your instructions to this client on the proper manner to collect this specimen? A. The need to cleanse the perineal area with circular wipes B. The need to cleanse the perineal area from the “dirtiest” to the “cleanest” C. The need to use a new antiseptic wipe for each wipe from the inner to the outer labia D. The need to use a new antiseptic wipe for each wipe from the outer to the inner labia Correct Response : C Explanation : A principle of asepsis is the cleansing of areas from the cleanest to the dirtiest and NOT the reverse; therefore, the inner labia are cleansed before the outer labia. The female perineal area is prepped with straight strokes and wipes, and the male wipes in a circular pattern around the urinary meatus. (See Clean Catch or Midstream Urine Specimen (Gender-Specific ) 10.Which of these procedures and/or conditions is improperly paired with the preferred client positioning? A. A client with hypovolemic shock should be in Trendelenburg. B. A client post lumbar puncture/spinal tap should be in left or right lateral decubitus. C. A client receiving an enema should be in Sims. D. A client undergoing a tube feeding should be in semi-Fowlers. Correct Response : B Explanation : Client positioning is not only important for client comfort and tolerance of a procedure, but it can also have a therapeutic effect and reduce the risk of unwanted complications. A client that is post lumbar puncture/spinal tap should be placed in a flat, supine position to help prevent the complication of post-procedural headaches and other complications. (See Implementing Precautions to Prevent Injury and Complications in Procedures and Diagnoses )

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