Author Question: A client presents to the family practice clinic reporting a week of watery, somewhat bloody ... (Read 33 times)

Themember4 · **on:** Jun 25, 2018

A client presents to the family practice clinic reporting a week of watery, somewhat bloody diarrhea. The nurse assists the client to obtain a stool sample. What action by the nurse is most important?

a. Ask the client about recent exposure to illness.
b. Assess the client's stool for obvious food particles.
c. Include the date and time on the specimen container.
d. Put on gloves prior to collecting the sample.

Question 2

A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority?

a. Auscultate for bowel sounds.
b. Notify the provider immediately.
c. Order an abdominal flat-plate x-ray.
d. Palpate the mass and measure its size.

kalskdjl1212 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: D
To avoid possible exposure to infectious agents, the nurse dons gloves prior to handling any bodily secretions. Recent exposure to illness is not related to collecting a stool sample. The nurse can visually inspect the stool for food particles, but it still needs analysis in the laboratory. The container should be dated and timed, but safety for the staff and other clients comes first.

Answer to Question 2

ANS: B
This observation could indicate an abdominal aortic aneurysm, which could be life threatening and should never be palpated. The nurse notifies the provider at once. An x-ray may be indicated. Auscultation is part of assessment, but the nurse's priority action is to notify the provider.