A nurse instructs a female client about collecting a midstream urine sample. Which statement made by the client is appropriate from the teaching provided by the nurse?
"I'll use each cleansing wipe twice."
"I'll clean the inside of the container with a wipe."
"I'll urinate a little then stop."
"I'll use the cleansing wipe from front to back."
The Correct Answer is D
A. Using each cleansing wipe twice is not appropriate, as this may cause cross-contamination; each wipe should be used once.
B. Cleaning the inside of the container is unnecessary and may introduce contaminants; only the outside should be kept clean.
C. The correct method involves urinating a little, stopping to allow for midstream collection, and then continuing to urinate; saying "then stop" may confuse the procedure.
D. Using the cleansing wipe from front to back is the correct technique for women to prevent urinary tract infections (UTIs) and ensure proper hygiene during sample collection.
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Correct Answer is ["B","D","E"]
Explanation
A. Assessing the client every 4 hours is insufficient; the nurse should assess the client more frequently to monitor for changes in condition and risk factors for falls.
B. Placing a fall-risk identification band on the client's wrist is essential for alerting all staff to the client's fall risk, thereby promoting safety.
C. Keeping the client's room dark at night increases the risk of falls; adequate lighting should be provided to help the client navigate safely.
D. Teaching the client to use the call light encourages them to seek assistance when needed, which can help prevent falls.
E. Keeping the client's bed in the lowest position minimizes the risk of injury if the client attempts to get out of bed without assistance.
Correct Answer is B
Explanation
A. While a high-protein diet can support healing, it does not directly prevent the transmission of infection.
B. Performing hand hygiene before, during, and after direct contact with the client is crucial to prevent the transmission of pathogens and is a fundamental practice in infection control.
C. Positive-pressure airflow is used for clients who are immunocompromised to prevent them from contracting infections, not for clients with existing infections.
D. Changing bed linens daily can contribute to infection control but is not as effective as hand hygiene in preventing transmission.