: 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 D
Explanation
Choice A rationale
Aging usually leads to a decrease in muscle tone of the bowel rather than an increase, which can result in slower bowel movements and constipation.
Choice B rationale
Gastric acid production tends to decrease with age, not increase. This can affect the digestion and absorption of nutrients, and also increase the risk of stomach infections.
Choice C rationale
The pH of the stomach tends to become less acidic (increase) as one ages, not decrease. This is often due to the reduced production of gastric acid.
Choice D rationale
Decreased intestinal peristalsis is a common physiological change in older adults. This slowing down of the intestinal movements can lead to constipation and other digestive issues.
Correct Answer is D
Explanation
Choice A rationale
Clients should be instructed to hold their breath for about 10 seconds after inhalation, not 2 seconds. This allows the medication to reach deeper into the lungs.
Choice B rationale
The MDI canister should not be washed after each use. Instead, it should be cleaned regularly to ensure proper functioning and avoid medication buildup.
Choice C rationale
Clients should be instructed to inhale the medication slowly and deeply over a few seconds, rather than quickly for 1 second. This ensures proper delivery of the medication to the lungs.
Choice D rationale
Shaking the MDI prior to administration is essential. This action mixes the medication evenly, ensuring that the correct dose is delivered with each puff.