A nurse is reinforcing teaching with a client who has diabetes mellitus about a 24-hour creatinine clearance test.

Which of the following statements should the nurse include in the teaching?

You should eat a protein-rich diet during the collection period.

You should record your blood glucose level each time you void.

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

You can cleanse your perineal area with an antiseptic towel each time before you void.

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is B

Explanation

This is done by aspirating a small amount of stomach contents and testing the pH using pH paper or a pH indicator strip. The pH of stomach contents is typically acidic (pH less than 5), indicating proper placement in the stomach.

Injecting air and listening for bubbling is not a reliable method to verify tube placement, as it can lead to complications such as pneumothorax.

Measuring gastric residual is done to assess the amount of gastric contents remaining in the stomach, but it does not confirm tube placement.

Adding food coloring to the formula is not a standard practice and does not provide reliable confirmation of tube placement.

X-ray is the gold standard method to confirm tube placement but is not typically done before every intermittent feeding unless there are concerns about tube placement

A. Restrict the client's sodium intake to 3 g per day. B. Position the client supine with legs elevated. C. Measure the client's abdominal girth daily. D. Keep the client's daily protein intake below 0.8 g/kg.

Correct Answer is C

Explanation

A.Sodium restriction is a key component in the management of ascites, as it helps to reduce fluid retention. However, the standard recommendation for sodium intake in ascites management is typically lower than 3 grams per day. The guideline is often around 2 grams or even less to effectively manage ascites. Thus, while the concept is correct, the specific amount in this option is slightly higher than usually recommended.

B.This is not generally recommended for clients with ascites. Lying flat can increase discomfort and pressure on the diaphragm, making breathing more difficult. Instead, positioning the client in a semi-Fowler's or Fowler's position can help alleviate respiratory distress by reducing pressure on the diaphragm.

C. This is a crucial intervention. Measuring abdominal girth daily provides a reliable way to monitor changes in the size of the abdomen, which reflects changes in the amount of ascitic fluid. It helps in assessing the effectiveness of treatment and detecting any rapid accumulation of fluid that might require intervention.

D.While protein restriction was traditionally recommended to prevent hepatic encephalopathy, more recent guidelines suggest that moderate protein intake should be maintained unless the client has severe hepatic encephalopathy. Adequate protein intake is necessary to prevent muscle wasting and support liver function, and it should generally be individualized based on the client’s condition.

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A nurse is reinforcing teaching with a client who has diabetes mellitus about a 24-hour creatinine clearance test. Which of the following statements should the nurse include in the teaching?

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A nurse is reinforcing teaching with a client who has diabetes mellitus about a 24-hour creatinine clearance test.

Which of the following statements should the nurse include in the teaching?