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 C
Explanation
Choice A rationale
Restricting the child’s strenuous activities for 3 days is important, but it is not the priority. Monitoring for signs of impaired circulation or complications is more critical.
Choice B rationale
Using a hair dryer on a cool setting to relieve itching can be helpful, but it is not the priority. The priority is to monitor for signs of impaired circulation.
Choice C rationale
Monitoring for pallor or swelling in the child’s affected hand is the priority because it can indicate impaired circulation or compartment syndrome, which are serious complications that require immediate attention.
Choice D rationale
Examining the child for skin irritation at the cast edges is important to prevent complications, but it is not the priority over monitoring for circulation and potential complications.
Correct Answer is D
Explanation
Choice A rationale
Encouraging flexion and extension of the neck is contraindicated for a client with a halo vest as it can compromise the stability of the cervical spine.
Choice B rationale
Assessing the pin sites for infection once every other day is not sufficient. Pin sites should be assessed at least once per shift to detect and manage any potential infections early.
Choice C rationale
Tightening the screws on the halo device one-quarter turn every 48 hours is not recommended. Adjustments to the halo device should only be made by a healthcare provider to ensure the integrity of the device and the stability of the cervical spine.
Choice D rationale
Repositioning the client using a turning sheet is the correct action. This method helps to reposition the client safely without exerting unnecessary pressure on the cervical spine and aids in preventing pressure ulcers.