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 B
Explanation
Choice A rationale
Administering a PRN sedative prescription should not be the first intervention as it does not address the underlying cause of the client’s confusion and wandering.
Choice B rationale
Leaving the door to the client’s room open slightly can help reduce feelings of isolation and anxiety by allowing the client to see and hear staff members as they pass by.
Choice C rationale
Applying wrist restraints should be a last resort and not the first intervention for managing wandering behavior.
Choice D rationale
Providing a back rub at bedtime may help promote relaxation but does not directly address the issue of wandering.