A nurse is teaching a newly licensed nurse about obtaining a fecal occult blood test from a client.
Which of the following information should the nurse include?
Collect two stool specimens from the same area of the stool.
Use toilet paper to transfer the stool specimen.
Apply four drops of developing solution to each stool specimen.
Wait 30 seconds after applying the developing solution to obtain the results.
The Correct Answer is D
Choice A rationale
Collecting two stool specimens from the same area of the stool is incorrect because specimens should be taken from different areas to ensure a representative sample of the stool for testing.
Choice B rationale
Using toilet paper to transfer the stool specimen is not recommended as it can contaminate the sample and interfere with test results.
Choice C rationale
Applying four drops of developing solution to each stool specimen is incorrect. The usual procedure involves applying a specific number of drops as indicated by the test instructions, which may vary.
Choice D rationale
Waiting 30 seconds after applying the developing solution is correct. This waiting period allows the test to react and provide accurate results for the presence of occult blood.
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Correct Answer is B
Explanation
Choice A rationale
Placing the client into a right lateral position is not the standard position for administering an enema. The left lateral (Sims') position is commonly used as it facilitates the flow of the
solution into the colon.
Choice B rationale
Warming the enema solution to room temperature helps ensure the client's comfort and can prevent cramping and discomfort. Cold solutions can cause discomfort and cramping,
making the procedure less tolerable for the client.
Choice C rationale
Sterile technique is not required for administering an enema. Clean technique is generally sufficient unless otherwise indicated by the client’s condition or specific medical orders.
Choice D rationale
Lubricating the tubing is essential to ensure smooth insertion and prevent trauma to the rectal mucosa, but an oil-based lubricant is not typically used as it can interfere with the
absorption of the enema solution. Water-soluble lubricants are preferred.
Correct Answer is D
Explanation
Choice A rationale
Instilling ophthalmic medication directly on the cornea can cause irritation and discomfort. Medications should be administered in the conjunctival sac.
Choice B rationale
Asking the client to tightly squeeze their eyes shut after instillation can expel the medication, reducing its effectiveness. Gentle closing of the eyes is recommended.
Choice C rationale
Cleaning the eye from the outer canthus to the inner canthus is not the proper method. The correct method is to clean from the inner canthus to the outer canthus to avoid contaminating the inner eye.
Choice D rationale
Applying pressure to the nasolacrimal duct after instillation helps prevent the medication from draining into the nasolacrimal system, ensuring better absorption in the eye.