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. Filling out an occurrence form is necessary for documentation and accountability but is not the immediate priority after a medication error.
B. Administering the medication to the correct client should be done, but first, the nurse must ensure the safety and well-being of the client who received the wrong medication.
C. Notifying the client's provider is essential, but the nurse should first assess the client's condition to determine if any immediate actions are necessary.
D. Checking the client's vital signs is the first action the nurse should take to assess the client's current condition and any potential adverse effects from receiving the incorrect medication.
Correct Answer is A
Explanation
A. Applying petroleum jelly to the client's lips after oral care helps to prevent dryness and cracking, especially important for immobile clients who may have decreased hydration.
B. A stiff toothbrush can cause damage to the gums and teeth; a soft-bristled toothbrush is preferable for gentle cleaning.
C. Using the thumb and index finger to keep the client's mouth open can cause discomfort; a tongue blade or a mouth prop may be a better option if needed.
D. While turning the client on their side can help if there is a risk of aspiration, it is not always necessary for every oral care session and depends on the client's specific condition.