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
Explanation
Choice A rationale
Verifying the placement of the pulse oximeter is the first step to ensure accurate readings. Incorrect placement can lead to false low oxygen saturation readings.
Choice B rationale
Increasing the oxygen to 3 L/minute may be necessary if the oxygen saturation remains low after verifying the pulse oximeter placement. However, it is not the immediate first step.
Choice C rationale
Removing the nasal cannula is not appropriate as it would further decrease the oxygen supply to the patient.
Choice D rationale
Switching to a non-rebreather mask is not the immediate action to take. Non-rebreather masks deliver a high concentration of oxygen, typically reserved for severe hypoxia.
Correct Answer is C
Explanation
Choice A rationale
Recording the client’s daily weight is not the most immediate concern for a terminally ill client who is weak and mouth breathing. The priority is to address comfort and hydration.
Choice B rationale
Maintaining the client in high Fowler’s position can help with breathing but does not directly address the issue of dry mucous membranes due to mouth breathing and refusal to eat or drink.
Choice C rationale
Keeping mucous membranes moist is crucial for comfort and preventing complications such as dryness and cracking, which can lead to infections. This intervention directly addresses the client’s symptoms and promotes comfort.
Choice D rationale
Reporting any change in urine color is important but not the most immediate concern for a terminally ill client who is weak and mouth breathing. The priority is to address comfort and hydration.