The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?
Begin the collection the next day.
Empty the sample into the 24-hour container.
Observe the sample for sediment.
Start collecting the specimen with the next void.
The Correct Answer is D
Choice A rationale
Beginning the collection the next day is not necessary. The 24-hour urine collection can be started immediately with the next void. Delaying the collection may cause unnecessary inconvenience and prolong the client’s hospital stay.
Choice B rationale
Emptying the sample into the 24-hour container is incorrect because the first urine sample should be discarded to ensure that the collection starts with an empty bladder. Including the initial sample would result in inaccurate measurement of creatinine clearance.
Choice C rationale
Observing the sample for sediment is not relevant to the collection process for creatinine clearance. The focus should be on ensuring accurate timing and collection of all urine produced within the 24-hour period.
Choice D rationale
Starting the collection with the next void is the correct action. The 24-hour urine collection should begin with an empty bladder, and the first urine of the day is discarded. The time is noted, and all subsequent urine is collected for the next 24 hours. This ensures accurate measurement of creatinine clearance.
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Correct Answer is ["A","C","D","E","F"]
Explanation
Choice A rationale
Double-checking all dosage calculations is a crucial error prevention technique. It helps ensure that the correct dose is administered and reduces the risk of medication errors. This step is especially important for medications like insulin, where precise dosing is critical.
Choice B rationale
This option seems incomplete and does not provide a clear error prevention technique. Therefore, it is not considered a correct choice.
Choice C rationale
Comparing the medication label to the order is essential to verify that the correct medication is being administered. This step helps prevent errors related to administering the wrong medication.
Choice D rationale
Using at least two client identifiers before administering a dose is a standard safety practice. It ensures that the medication is given to the correct patient and helps prevent errors related to patient misidentification.
Choice E rationale
Involving and educating clients in medication administration can help prevent errors by ensuring that clients are aware of their medications and can alert healthcare providers to any discrepancies. This collaborative approach enhances patient safety.
Choice F rationale
Documenting all medication in the electronic record as soon as it is given is crucial for maintaining accurate and up-to-date records. This practice helps prevent duplicate dosing and ensures that all healthcare providers have access to the most current information.
Correct Answer is D
Explanation
Choice A rationale
Expelling the air in the prefilled syringe prior to injection is not recommended for low molecular weight heparin (LMWH) administration. The air bubble in the prefilled syringe helps ensure the entire dose is delivered and prevents leakage of the medication. Removing the air bubble can lead to an incomplete dose and reduced efficacy of the medication.
Choice B rationale
Rotating injections between the abdomen and gluteal areas is not recommended for LMWH administration. The preferred site for LMWH injections is the abdominal area, specifically at least 2 inches (5.1 cm) from the umbilicus. This site provides better absorption and reduces the risk of complications such as hematoma formation.
Choice C rationale
Massaging the injection site to increase absorption is not recommended for LMWH administration. Massaging the site can cause bruising and hematoma formation, which can be painful and may affect the absorption of the medication. It is important to avoid massaging the injection site to minimize these risks.
Choice D rationale
Injecting in the abdominal area at least 2 inches (5.1 cm) from the umbilicus is the correct instruction for LMWH administration. This site provides optimal absorption and reduces the risk of complications. The abdominal area has a good blood supply, which helps in the effective absorption of the medication. Additionally, injecting at least 2 inches (5.1 cm) from the umbilicus helps avoid the umbilical area, which is more prone to bruising and discomfort.