A nurse is caring for a client who has a prescription for warfarin.

Which of the following laboratory tests should the nurse monitor?

C, "You can begin collection of urine after discarding your first morning void."

A 24-hour creatinine clearance test is used to evaluate how well the kidneys are functioning by measuring the amount of creatinine in the blood and urine over a 24-hour period. During the test, the client is asked to discard their first morning void and then collect all urine for the next 24 hours.

Option A is incorrect because a protein-rich diet can affect the creatinine levels in the urine, which can result in inaccurate test results. Therefore, the nurse should advise the client to avoid a protein-rich diet during the collection period.

Option B is incorrect because blood glucose levels are not relevant to a 24-hour creatinine clearance test. Therefore, the nurse should not ask the client to record their blood glucose level each time they void.

Option D is incorrect because using an antiseptic towel to cleanse the perineal area can also affect the test results by introducing contaminants into the urine sample. Therefore, the nurse should advise the client to cleanse the perineal area with soap and water or an alcohol wipe.

Choice A Reason:

Blaming the assistive personnel without additional information or evidence may not be appropriate and should be investigated further.

Choice B Reason:

Mentioning that an incident report has been completed and sent to risk management is important for institutional record-keeping and follow-up but does not provide details about the incident itself.

Choice C Reason:

"Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom'." In the documentation of a client fall, it is important to include the client's own account of the incident, as this can provide valuable information about the circumstances surrounding the fall. Including direct quotes or statements from the client helps to accurately capture their perspective and can be useful for assessing the root causes of the fall and developing appropriate interventions to prevent future falls.

Choice D Reason:

Documenting that the client does not appear to have any injuries is relevant but does not provide information about the circumstances of the fall, which is important for a comprehensive understanding of the event.