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.

Correct Answer: C

Rationale: Assisting the client to stand by the side of the bed to void is the most appropriate action. This position can help stimulate voiding due to gravity and normal positioning. Having the client drink water (Choice A) may help, but assisting him to stand is more effective. Crede maneuver (Choice B) is not recommended as it can increase the risk of bladder trauma. Waiting for 2 hours (Choice D) without taking any action is not proactive in addressing the client's inability to void.

Correct Answer: A

Rationale: To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia by removing too much oxygen from the patient. Maintaining a sterile technique (choice B) is important to prevent infection but does not directly relate to preventing hypoxia. Lubricating the catheter tip (choice C) helps with the insertion process but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not contribute to preventing hypoxia.

Correct Answer: C

Rationale: Rationale: The correct answer is C) "The medication must be continued so the fluid problem is controlled." Explanation: In congestive heart failure (CHF), the primary goal of diuretic therapy is to manage fluid overload and reduce symptoms such as edema and shortness of breath. Diuretics help the body eliminate excess fluid, reducing the workload on the heart. However, CHF is a chronic condition that requires ongoing management. Discontinuing diuretics can lead to fluid retention, worsening symptoms, and potential exacerbation of heart failure. Therefore, it is crucial for the client to continue taking the medication as prescribed to maintain fluid balance and prevent complications associated with CHF. Why the other options are wrong: A) "As you urinate more, you will need less medication to control fluid." This statement oversimplifies the relationship between diuretics and fluid management in CHF. Adjusting diuretic dosage should be done under healthcare provider supervision based on individual response and clinical assessment. B) "You will have to take this medication for about a year." This response sets a specific timeframe for diuretic therapy, which may not be accurate for all patients with CHF. Duration of diuretic therapy should be determined based on ongoing evaluation of the patient's condition. D) "Please talk to your health care provider about medications and treatments." While it is important for the client to communicate with their healthcare provider, this response does not address the specific question about the duration of diuretic therapy in CHF. Educational context: Understanding the rationale behind the need for ongoing diuretic therapy in CHF is crucial for nursing practice. Nurses play a key role in educating patients about their medications and treatment plans to promote adherence and optimize health outcomes. By explaining the importance of continuing diuretic therapy to control fluid balance in CHF, nurses empower patients to take an active role in managing their condition and improving their quality of life.

Correct Answer: D

Rationale: For a client with a percutaneous endoscopic gastrostomy (PEG) tube, flushing the tube adequately with water before and after use is essential. This action helps prevent clogging and ensures the proper administration of feedings and medications. Choice A is incorrect because pulverizing all medications into a powdery condition is not necessary for PEG tube administration. Choice B is incorrect as squeezing the tube to break up stagnant liquids may damage the tube. Choice C is incorrect because cleansing the skin around the tube daily with hydrogen peroxide can be too harsh and lead to skin irritation.