: 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
The end of the stoma is typically not painful after the procedure. Pain at the stoma site could indicate complications such as infection or ischemia.
Choice B rationale
A healthy stoma should be pink or red in color. A purple color could indicate compromised blood flow or other complications that require medical attention.
Choice C rationale
The stoma is typically placed in the right lower abdomen to allow for easier management and care, as it is usually associated with the terminal ileum.
Choice D rationale
After an ileostomy, the stool is usually liquid to semi-formed, not solid, because the colon, which absorbs water to solidify stool, is bypassed.
Correct Answer is D
Explanation
Choice A rationale
Blood in the urine (hematuria) is not a typical finding in urinary retention. It may indicate other conditions such as infection, stones, or malignancy.
Choice B rationale
Cloudy urine is often a sign of infection, not typically associated with urinary retention. It can be caused by the presence of bacteria, white blood cells, or crystals.
Choice C rationale
Dark-colored urine can result from dehydration or certain foods and medications. It is not a specific finding of urinary retention.
Choice D rationale
Leakage of urine, also known as overflow incontinence, can occur in urinary retention. This happens when the bladder becomes overly full, and small amounts of urine leak out due to the pressure.