: A nurse is preparing to obtain a 24-hr urine collection from a client.
Which of the following actions should the nurse plan to take?
Include toilet paper with the collected urine.
Save the first void at the start of the collection time period.
Refrigerate the urine during the collection time period.
Discard the client's last void at the end of the collection time period.
The Correct Answer is C
Choice A rationale
Including toilet paper with the collected urine can contaminate the sample and affect the accuracy of the test results.
Choice B rationale
The first void at the start of the collection period should be discarded to ensure that only urine produced during the 24-hour period is collected.
Choice C rationale
Refrigerating the urine during the collection period helps preserve the sample and prevent bacterial growth, which could alter the test results.
Choice D rationale
The last void at the end of the collection period should be included to ensure that the full 24-hour period is accounted for in the collection.
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Correct Answer is C
Explanation
Choice A rationale
Returning the opened medication to the medication cart is inappropriate because once a medication is opened and refused by a client, it must be disposed of properly. This action helps maintain safety and prevents contamination.
Choice B rationale
Reporting the incident to the provider is not necessary in this context as the refusal to take medication can be managed by the nurse by following the facility's protocol.
Choice C rationale
Filling out an incident report is required because the client's refusal to take the medication is considered a significant event. Incident reports are used to document and analyze such events to improve patient care and safety.
Choice D rationale
Notifying the facility's ethics committee is unnecessary for a medication refusal incident, as it does not involve an ethical dilemma requiring their intervention.
Correct Answer is B
Explanation
Choice A rationale
White rice is a low-fiber food that is usually recommended to help manage diarrhea, as it can help firm up stools.
Choice B rationale
Caffeinated beverages can increase intestinal motility and secretions, leading to diarrhea. They can also be irritating to the gastrointestinal tract.
Choice C rationale
Low-fiber cereals are less likely to cause diarrhea and are often recommended for those with diarrhea because they are easy to digest.
Choice D rationale
Ripe bananas are low in fiber and high in potassium, which is beneficial for those with diarrhea as they help in firming up the stool.