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.

Answer and Explanation

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.

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Correct Answer is ["31"]

Explanation

Step 1: Calculate the total volume to be infused. Total volume = 250 mL.

Step 2: Calculate the total time for the infusion in minutes. Total time = 2 hours × 60 minutes/hour = 120 minutes.

Step 3: Calculate the flow rate in mL/min. Flow rate = Total volume ÷ Total time = 250 mL ÷ 120 min = 2.08 mL/min.

Step 4: Calculate the flow rate in drops/min. Flow rate = 2.08 mL/min × 15 drops/mL = 31.25 drops/min. So, the nurse should adjust the flow rate to deliver approximately 31 drops per minute.

A. To remove gastric acid that might cause dyspepsia B. To identify delayed gastric emptying C. To determine the patient’s electrolyte balance D. To confirm the placement of the NG tube

Correct Answer is B

Explanation

Choice A rationale

While gastric acid can cause dyspepsia, measuring gastric residual is not primarily done to remove gastric acid.

Choice B rationale

Measuring gastric residual is primarily done to identify delayed gastric emptying. This is important because delayed gastric emptying can lead to complications such as aspiration pneumonia.

Choice C rationale

Gastric residual does not directly determine the patient’s electrolyte balance.

Choice D rationale

While confirming the placement of the NG tube is important, it is not the primary purpose of measuring gastric residual.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to infuse a 250-mL unit of packed red blood cells (RBCs) over 2 hours. The drop factor of the manual intravenous (IV) tubing is 15 drops/mL. How many drops per minute should the nurse adjust the flow rate to deliver?

Correct Answer is ["31"]

Explanation

A nurse is caring for a patient who receives intermittent enteral feedings through an NG tube.Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

Correct Answer is B

Explanation

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