A nurse is preparing to obtain a 24-hour urine collection from a client. Which of the following actions should the nurse plan to take?
Refrigerate the urine during the collection time period.
Discard the client’s last void at the end of the collection time period.
Include toilet paper with the collected urine.
Save the first void at the start of the collection time period.
The Correct Answer is A
Choice A rationale
The nurse should plan to refrigerate the urine during the collection time period. This is because the urine needs to be kept cool to prevent the breakdown of certain analytes that might be measured in the urine.
Choice B rationale
The nurse should not discard the client’s last void at the end of the collection time period. The last voided specimen should be included in the collection to ensure that the 24-hour collection is complete.
Choice C rationale
The nurse should not include toilet paper with the collected urine. Toilet paper could contaminate the urine sample and interfere with the accuracy of the test results.
Choice D rationale
The nurse should not save the first void at the start of the collection time period. The first voided specimen should be discarded, and the collection should start with the next void.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Discarding any residual gastric contents before administering the tube feeding is not necessary and could lead to unnecessary loss of nutrients and electrolytes.
Choice B rationale
Positioning the patient in a low Fowler’s position is not the optimal position for administering a tube feeding. The patient should be in an upright position to reduce the risk of aspiration.
Choice C rationale
Testing the pH of the gastric aspirate is an important step before administering a tube feeding. This helps to verify that the feeding tube is in the stomach and not in the lungs.
Choice D rationale
Warming the feeding solution to body temperature is not necessary and could potentially lead to bacterial growth in the feeding solution.
Correct Answer is B
Explanation
Choice A rationale
While observing the patient’s respiratory status is important in all patient care, it is not the priority action in this case. The patient’s decreased level of consciousness and inability to swallow increase the risk of aspiration, which can lead to respiratory complications.
Choice B rationale
Elevating the head of the patient’s bed 30° to 45° is the priority action. A patient who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying down also increases this risk. The priority action by the nurse is to keep the head of the bed elevated to promote gastric emptying and reduce the risk of aspiration.
Choice C rationale
Monitoring intake and output every 8 hours is important for assessing the patient’s hydration status and nutritional needs. However, it is not the priority action in this case. The risk of aspiration due to the patient’s decreased level of consciousness and inability to swallow takes precedence.
Choice D rationale
Checking residual volume every 4 to 6 hours is a standard practice when administering continuous enteral feedings through a gastrostomy tube. It helps to ensure that the patient is tolerating the feedings and not at risk for aspiration due to high gastric residuals. However, in this case, the priority is to prevent aspiration by elevating the head of the bed.
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