A nurse is providing instructions about a 24-hour urine collection to an adolescent client. Which of the following should the nurse include in the teaching?
Discard the first voided specimen.
Void every hour.
Save the final specimen in a separate container.
Cleanse the perineum with a povidone-iodine solution prior to voiding.
The Correct Answer is A
Choice A rationale
The first voided specimen is discarded to ensure that the 24-hour urine collection starts with an empty bladder and accurately reflects the urine produced over the entire period.
Choice B rationale
Voiding every hour is not necessary and may not be practical for a 24-hour urine collection.
Choice C rationale
The final specimen should be included in the same container as the rest of the 24-hour urine collection.
Choice D rationale
Cleansing the perineum with a povidone-iodine solution is not required for a 24-hour urine collection.
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Correct Answer is B
Explanation
Choice A rationale
White grape juice is high in sugar and may worsen diarrhea. High-sugar beverages can draw water into the intestines, leading to increased stool output and worsening dehydration.
Choice B rationale
Oral electrolyte solution helps prevent dehydration and replaces lost electrolytes in infants with acute diarrhea, making it the most appropriate choice. Oral rehydration solutions are specifically formulated to provide the right balance of electrolytes and fluids to manage dehydration caused by diarrhea.
Choice C rationale
Chicken soup is not recommended as it may be too heavy and rich for an infant with acute diarrhea. Additionally, it may not provide the necessary electrolytes and fluids needed to manage dehydration.
Choice D rationale
Applesauce may worsen diarrhea due to its high sugar content. Similar to white grape juice, high-sugar foods can draw water into the intestines and increase stool output.
Correct Answer is D
Explanation
Choice A rationale
An adolescent with a urinary tract infection (UTI) is not at high risk for insufficient vascular perfusion. UTIs primarily affect the urinary system and do not typically impact vascular perfusion.
Choice B rationale
A toddler receiving intravenous fluids is not at high risk for insufficient vascular perfusion. IV fluids help maintain hydration and vascular volume, supporting adequate perfusion.
Choice C rationale
A preschooler with otitis media (ear infection) is not at high risk for insufficient vascular perfusion. Otitis media affects the middle ear and does not typically impact vascular perfusion.
Choice D rationale
A school-age child in a spica cast is at high risk for insufficient vascular perfusion. The cast can restrict blood flow, leading to complications such as compartment syndrome, which requires immediate medical attention.