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 B

Explanation

Choice A reason: Electrolyte solutions address dehydration but are inappropriate for pale, cool, lethargic symptoms in Tetralogy of Fallot (TOF), indicating a hypercyanotic spell from right-to-left shunting. Urgent medical intervention restores oxygenation, making this inadequate compared to addressing the critical hypoxic episode requiring provider attention.

Choice B reason: Pale, cool, lethargy in TOF signals a hypercyanotic spell, where pulmonary stenosis increases right-to-left shunting, causing cyanosis and hypoxia. Contacting the provider ensures rapid interventions (e.g., oxygen, beta-blockers), preventing cerebral hypoxia or cardiac arrest, addressing the urgent pathophysiological crisis effectively.

Choice C reason: Quiet time by holding or rocking may calm the toddler but does not treat hypoxic spells in TOF, where pale, cool symptoms indicate shunting and hypoxia. Delaying medical intervention risks severe hypoxia, making this less critical than contacting the provider for urgent management.

Choice D reason: A recumbent position worsens TOF’s hypercyanotic spell, increasing venous return and shunting, exacerbating hypoxia. Knee-chest positioning reduces shunting. Contacting the provider is urgent to address pale, cool, lethargic symptoms, ensuring interventions to restore oxygenation, making this position contraindicated.

A. Blood pressure of 100/80 mm Hg. B. Abdominal pulse noted on inspection. C. Urinalysis with 1 to 4 WBC/lpf. D. Urinary output of 30 mL/hour.

Correct Answer is D

Explanation

Choice A reason: A blood pressure of 100/80 mm Hg is low but not specific for renal perfusion without context. Urinary output directly reflects kidney function, with 30 mL/hour indicating possible oliguria. Monitoring output is critical, per renal assessment and acute kidney injury management protocols in nursing care.

Choice B reason: Abdominal pulse on inspection is unrelated to renal perfusion, typically indicating vascular issues like aneurysms. Urinary output is a direct indicator of kidney function, with 30 mL/hour suggesting reduced perfusion. This is irrelevant, per renal assessment and diagnostic standards in nephrology nursing.

Choice C reason: Urinalysis with 1 to 4 WBC/lpf is within normal range and suggests no infection. Urinary output of 30 mL/hour is concerning for decreased renal perfusion, requiring close monitoring. WBCs are less critical, per renal function and acute kidney injury assessment guidelines in nursing.

Choice D reason: Urinary output of 30 mL/hour indicates possible oliguria, a key sign of decreased renal perfusion. Monitoring this parameter assesses kidney function, guiding interventions to prevent acute kidney injury. It is the most direct indicator, per renal perfusion and critical care protocols in nephrology nursing practice.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

Correct Answer is B

Explanation

The nurse is assessing a client who is admitted to the renal unit with suspected decreased renal perfusion. The nurse should plan to carefully monitor which parameter? Reference Range: Urine white blood cells (WBC) [0 to 4 WBC/low powered field (lpf)]

Correct Answer is D

Explanation

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