a nurse is to collect a sputum specimen for acid fast bacillus afb from a client which action should the nurse take first
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Nursing Elites

HESI RN

HESI Nutrition Exam

1. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?

Correct answer: D

Rationale: Assisting with oral hygiene is the essential initial step before collecting a sputum specimen for acid-fast bacillus (AFB) to prevent contamination of the sample. Ensuring the client's mouth is clean reduces the risk of introducing unwanted bacteria into the specimen. Asking the client to cough sputum into a container, having the client take deep breaths, and providing a specimen container are important steps in the specimen collection process, but they should follow ensuring proper oral hygiene.

2. A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?

Correct answer: A

Rationale: The most crucial point to reinforce to the patient after a vasectomy is the need for continued contraception until it is confirmed that the ejaculate is sperm-free. Choice A emphasizes this by highlighting the importance of using another form of contraception until the healthcare provider confirms the absence of sperm. This is essential to prevent unintended pregnancies. Choices B, C, and D do not address the key point of ensuring contraception until sperm absence is confirmed and are therefore not as important to reinforce in this scenario.

3. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first?

Correct answer: C

Rationale: The correct answer is to place the child in respiratory/secretion precautions first. Meningococcal meningitis is highly contagious, and respiratory precautions are essential to prevent the spread of the infection. Seizure precautions may be necessary but are not the priority upon admission. Monitoring neurologic status is important but not the initial action needed. While antibiotic therapy like Cefotaxime is crucial, implementing isolation precautions to prevent transmission takes precedence in this situation.

4. A nurse at a provider's office is reinforcing teaching with a client who is being treated with chemotherapy and is losing weight. Which of the following instructions should the nurse give to increase the client's caloric intake? (Select one that doesn't apply).

Correct answer: D

Rationale: Increasing fluids during meals does not directly contribute to increasing caloric intake. Topping yogurt with granola, using honey on toast, and using milk instead of water in recipes are effective ways to boost caloric intake. While adequate fluid intake is important for hydration and overall health, it does not address the specific need to increase caloric intake in this scenario.

5. A nurse is reinforcing teaching with the mother of a 9-month-old infant regarding appropriate dietary choices. Which of the following observations by the nurse indicates a need for further teaching?

Correct answer: C

Rationale: The correct answer is C. Infants should not consume more than 24 ounces of milk a day as it can lead to iron deficiency anemia and other issues. Choices A and B demonstrate appropriate dietary choices for a 9-month-old, as they involve providing the infant with family foods and appropriate finger foods. Choice D is also appropriate as it shows the infant is transitioning to drinking from a cup.

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