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 D
Explanation
A. Proceeding to measure the oral temperature immediately after the client has consumed ice chips can lead to an inaccurate reading due to the cooling effect of the ice.
B. Documenting that the nurse was unable to measure the client's temperature is unnecessary; it is possible to obtain an accurate measurement after a suitable waiting period.
C. Providing a sip of warm water will not resolve the issue of the ice chips affecting the temperature reading, as the nurse should still wait a longer period for accuracy.
D. Waiting 30 minutes after the client has consumed ice chips is the best practice, as it allows sufficient time for the oral cavity to return to a baseline temperature for an accurate measurement.
Correct Answer is A
Explanation
A. Dehydration is a common finding in clients who have experienced diarrhea for several days, as they may have lost significant fluid and electrolytes.
B. A rigid abdomen is more characteristic of conditions such as perforation or severe peritonitis rather than diarrhea.
C. Decreased bowel sounds may occur in certain conditions, but diarrhea typically presents with increased bowel sounds due to hyperactivity.
D. Hypothermia is not a common finding associated with diarrhea; instead, clients may have a normal or elevated temperature due to potential underlying infections.