A client started a 24-hour urine collection several hours ago. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. Which intervention should the nurse initiate?
Notify the charge nurse of the problem.
Notify the healthcare provider of the situation.
Discard the urine and start another 24-hour period.
Add another hour to the urine collection period.
The Correct Answer is C
A. While it’s important to inform the charge nurse of any issues with the collection process, this action alone does not address the core problem of the collection being compromised. The charge nurse may offer guidance or assist in deciding the next steps, but the primary focus should be on correcting the collection process to ensure accurate results.
B. Notifying the healthcare provider can be important, especially if the results of the 24-hour urine collection are critical to the client’s diagnosis or treatment plan. However, it is usually more efficient to first address the issue of the collection itself and then inform the healthcare provider about the results of these corrective actions.
C. This is the most appropriate action when a mistake occurs in the collection process, such as flushing a voided sample. The integrity of the collection is compromised, and starting a new 24-hour collection period ensures that all samples are accounted for and that the results will be accurate.
D. Adding extra time to the urine collection period does not compensate for the missed sample. The accuracy of the collection depends on having all urine samples from the full 24-hour period.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. High doses of fish oil can indeed increase the risk of bleeding, particularly because fish oil has anticoagulant properties that can interfere with blood clotting. This risk is especially significant if the client is also taking other anticoagulant or antiplatelet medications.
B. While it is true that fish can be heart-healthy due to its omega-3 fatty acids, this statement does not fully address the concerns about the safety of high doses of fish oil supplements. Eating fish in moderate amounts is beneficial, but the focus here is on the effects of large doses of fish oil supplements, not just consuming fish. The safety of high doses should be considered separately.
C. Encouraging the client to increase the dose of fish oil is not appropriate without considering potential side effects and risks. High doses of fish oil can lead to gastrointestinal symptoms like nausea, diarrhea, and indigestion.
D. Not all types of oils increase cholesterol and triglycerides. For instance, omega-3 fatty acids found in fish oil can actually help lower triglyceride levels and may have a positive effect on cholesterol levels.
Correct Answer is A
Explanation
A. After a myocardial infarction, it is important to monitor the client’s blood pressure before they start ambulating to assess their hemodynamic stability. Changes in blood pressure during or after ambulation could indicate problems such as orthostatic hypotension or cardiovascular instability.
B. While monitoring urinary output is important for assessing renal function and fluid balance, it is not the most immediate concern when preparing the client to ambulate post-MI. The priority is to ensure cardiovascular stability and safety during ambulation, so other interventions take precedence in this situation.
C. Dietary teaching about a cardiac diet is important for long-term management and recovery after an MI. However, it is not the immediate concern when the client is preparing to ambulate for the first time. The priority at this moment is to ensure the client’s safety and stability during the initial physical activity.
D. Vital signs should certainly be monitored, but the more immediate concern when the client is preparing to ambulate is ensuring cardiovascular stability and assessing any potential risk factors that could arise during the activity.
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