A nurse is caring for a child who is 2 hr postoperative.

Exhibits

Which of the following actions should the nurse take first? (Click the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

A. During a 24-hour urine collection, all urine produced over the 24-hour period should be collected in a single container. The final specimen (the last urine voided at the end of the 24 hours) should be added to the same container as the rest of the collected urine, not saved separately.
B. For a 24-hour urine collection, there is no need to cleanse the perineum with a povidone-iodine solution before each collection. The focus should be on collecting all urine over the 24-hour period in the designated container. However, proper hygiene practices are important to avoid contamination.
C. The 24-hour urine collection starts after the first void of the day, which should be discarded. The collection begins with the second void and continues until the same time the next day, including the final void. Discarding the first void is essential to ensure that the collection accurately reflects the urine produced over a full 24-hour period.
D. During a 24-hour urine collection, the client should void as needed but collect all urine produced over the 24 hours in the designated container. There is no requirement to void every hour; the key is to ensure that every drop of urine is collected and included in the total 24-hour collection period.

A. The halo vest immobilizes the cervical spine completely. Any movement that might disturb the alignment of the spine is contraindicated. Using a turning sheet could potentially cause movement and damage the spine.
B. Tightening the screws without medical direction can be harmful. The screws should be checked regularly by healthcare professionals, and adjustments made as needed.
C. The entire purpose of the halo vest is to immobilize the neck. Any movement of the neck could disrupt the healing process and cause further injury.
D. Pin site care is crucial to prevent infection. The nurse should assess the pin sites regularly for signs of infection, such as redness, swelling, drainage, or increased pain.