A nurse is caring for a client who is at the end of life.
The client's partner is concerned about using opioid narcotics to manage the client's pain.
Which of the following statements should the nurse make?

Choice A rationale:

The client who is unresponsive to verbal commands and changes position occasionally is at the highest risk for developing a pressure injury. Pressure injuries, also known as pressure ulcers or bedsores, are more likely to occur in clients who cannot independently reposition themselves. Unresponsive clients are unable to sense discomfort and adjust their positions, which makes them particularly vulnerable to pressure injuries. Changing position occasionally may not be sufficient to prevent these injuries in such clients. Pressure injuries are a result of prolonged pressure on a particular area, causing damage to the skin and underlying tissues due to reduced blood flow. Clients who are unresponsive need more vigilant monitoring and frequent repositioning to prevent pressure injuries.

Choice B rationale:

The client who is alert and responsive and eats 25% of each meal is not at the highest risk for developing a pressure injury. While this client may have some nutritional concerns, the primary risk factor for pressure injuries is immobility or the inability to change position independently. The ability to eat some of each meal indicates at least some level of mobility and participation in activities of daily living, which can help reduce the risk of pressure injuries.

Choice C rationale:

The client who is receiving enteral feeding and can change position independently is not at the highest risk for developing a pressure injury. Enteral feeding provides adequate nutrition, and the ability to change position independently reduces the risk of pressure injuries. Changing positions helps distribute pressure and prevents localized areas of prolonged pressure that can lead to tissue damage.

Choice D rationale:

The client who makes frequent slight changes in position and walks occasionally is also not at the highest risk for developing a pressure injury. Walking and frequent position changes help in preventing pressure injuries. The risk is lower for clients who can independently make slight changes in position and engage in ambulation. These activities promote blood flow and relieve pressure on specific areas of the body.

Choice A rationale:

Discard the client's last void at the end of the collection time period. This choice is not appropriate. When conducting a 24-hour urine collection, it's essential to include all urine produced during the specified time frame. Discarding the last void would result in an incomplete and inaccurate collection.

Choice B rationale:

Include toilet paper with the collected urine. This choice is also incorrect. Toilet paper is not typically included in a 24-hour urine collection. The purpose of this collection is to accurately measure substances excreted by the kidneys over a specific time period. Toilet paper is not part of this measurement and should not be included.

Choice D rationale:

This helps prevent the breakdown of certain substances and ensures the sample's accuracy. Failure to refrigerate the urine can lead to inaccurate test results. Now, let's discuss the rationale for the correct answer, choice C:

Choice C rationale:

The first void at the beginning of the collection period is typically discarded, as it represents the urine that was in the bladder before the timed collection started. This helps ensure that the collection is accurate and only includes urine produced during the specified 24-hour period. It's important to follow this protocol to obtain reliable test results.