A nurse is reinforcing teaching with a client who has gestational hypertension about collecting a 24-hr urine specimen for protein. Which of the following statements should the nurse include in the teaching?
"Cleanse your perineum with povidone-iodine prior to collecting each urine specimen."
"You should start the 24-hour collection with your first urination."
"You should record the time on the collection container of any missed urine specimens."
"Do not add a urine specimen to the collection container if it contains stool
The Correct Answer is C
A) Incorrect- Cleansing the perineum with povidone-iodine is not relevant to the collection process.
B) Incorrect- The 24-hour collection should start with the first-morning urination, not with any random urination.
C) Correct - Recording the time on the collection container for any missed urine specimens is important for accurate measurement.
D) Incorrect- Stool should not be added to the urine collection container, but this is not the most important point to emphasize in this teaching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect- Abdominal breathing is a normal pattern in newborns and does not require immediate reporting.
B) Correct - Grunting is a sign of respiratory distress in a newborn and should be reported to the provider for further evaluation.
C) Incorrect- A respiratory rate of 55/min is within the normal range for a newborn and does not require immediate reporting.
D) Incorrect- Irregular respirations are common in newborns and may not necessarily be indicative of a problem.
Correct Answer is B
Explanation
A) Incorrect- A 20-gauge needle is too large and could cause unnecessary pain for the newborn.
B) Correct - Choosing a 3/8-inch needle is appropriate for administering vaccines to newborns. he hepatitis B vaccine is given intramuscularly in the anterolateral thigh of newborns. The needle size should be appropriate for the muscle mass and age of the infant. A 3/8-inch needle is recommended for newborns, while a 20-gauge needle is too large and may cause tissue damage.
C) Incorrect- Administering the vaccine into the dorsal gluteal muscle is not recommended because of the risk of injury to the sciatic nerve; the recommended site is the vastus lateralis muscle in the anterolateral thigh.
D) Incorrect- The hepatitis B vaccine is usually administered in a dose of 0.5 mL for newborns, but this is not the only action that the nurse should take.
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