The nurse is initiating a 24-hour urine collection for a client with an indwelling urinary catheter. After emptying all the urine from the collection bag, which action is most important for the nurse to implement?

Start the collection time now and stop the collection the next day at the same time.

Provide catheter care at the urinary site to prevent contamination of the specimens.

Clamp the catheter to control urine flow during the collection period.

Label the collection container with the client’s name and start time.

Answer and Explanation

The Correct Answer is A

Choice A reason: Starting the collection time after emptying the bag ensures an accurate 24-hour urine sample, critical for diagnostic tests like creatinine clearance. This defines the collection period, per laboratory and diagnostic specimen collection protocols in nursing practice.

Choice B reason: Catheter care prevents infection but is not the most critical step for initiating a 24-hour collection. Starting the collection time ensures accurate timing, essential for valid results, per urinary specimen collection and infection control standards in nursing.

Choice C reason: Clamping the catheter is inappropriate, as it disrupts continuous urine flow, skewing the 24-hour collection. Starting the collection time ensures accurate sampling, critical for diagnostic accuracy, per urinary catheter management and laboratory protocols in nursing practice.

Choice D reason: Labeling the container is important but secondary to starting the collection time, which defines the 24-hour period for accurate results. Timing ensures valid diagnostic data, per specimen collection and laboratory standards in nursing practice for urine collections.

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Correct Answer is A

Explanation

Choice A reason: Difficulty swallowing secretions in croup signals severe airway narrowing from subglottic edema, often parainfluenza-induced. This risks stridor and obstruction, leading to respiratory distress or hypoxia. It requires urgent evaluation for corticosteroids or epinephrine, prioritizing airway patency over less critical symptoms, preventing life-threatening complications.

Choice B reason: Fever of 101.0°F (38.3°C) is common in croup, indicating viral infection, but less urgent than swallowing difficulty, which suggests critical airway compromise. Fever is managed with antipyretics, but severe edema risking obstruction necessitates immediate intervention, making this a lower priority concern.

Choice C reason: Crying when nursing may reflect croup’s sore throat or breathing difficulty but is less specific than swallowing difficulty, indicating severe airway narrowing. Crying does not directly signal life-threatening obstruction, making it less urgent than symptoms of significant subglottic inflammation requiring medical attention.

Choice D reason: Barking cough, worse at night, is typical in croup from subglottic inflammation but managed with supportive care or steroids. Difficulty swallowing secretions indicates severe airway compromise, risking obstruction, requiring urgent intervention over a cough, which is an expected, less critical symptom.

A. Protein and albumin. B. Complete blood count (CBC). C. BUN and creatinine. D. Electrolytes.

Correct Answer is B

Explanation

Choice A reason: Protein and albumin reflect nutritional or liver status but are unaffected by enoxaparin, a low-molecular-weight heparin inhibiting factor Xa. These do not monitor anticoagulation effects or complications like bleeding. CBC is critical, as enoxaparin increases bleeding risk, requiring platelet and hemoglobin monitoring to detect serious hematological issues.

Choice B reason: Enoxaparin, an anticoagulant, heightens bleeding risk and can cause thrombocytopenia. Monitoring CBC, especially platelets and hemoglobin, detects heparin-induced thrombocytopenia (HIT) or hemorrhage. This ensures early identification of complications, allowing timely intervention to prevent severe bleeding or thrombosis, making CBC the most critical test for safe administration.

Choice C reason: BUN and creatinine assess renal function, relevant for renally cleared drugs, but enoxaparin is primarily liver-metabolized. Renal monitoring is secondary unless severe impairment exists. CBC is more urgent, as enoxaparin’s anticoagulant effect increases bleeding risk, necessitating hematological surveillance to prevent life-threatening complications.

Choice D reason: Electrolytes like potassium or sodium are not directly affected by enoxaparin’s action on the coagulation cascade. Imbalances may occur in critical illness but are not primary concerns. CBC monitoring for bleeding or thrombocytopenia is critical, as enoxaparin’s anti-Xa activity poses hematological risks requiring immediate attention.

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The nurse is initiating a 24-hour urine collection for a client with an indwelling urinary catheter. After emptying all the urine from the collection bag, which action is most important for the nurse to implement?

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