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 B
Explanation
Choice A rationale
Assessing the strength of deep tendon reflexes is not the most important intervention because the deep tendon reflexes are not the most reliable indicator of the serum potassium level. The nurse should check the client’s reflexes and note any hyperreflexia or hyporeflexia, but these are not the priority assessments.
Choice B rationale
This is the most important intervention because a high serum potassium level can cause cardiac dysrhythmias, which can be life-threatening. The nurse should monitor the client’s heart rate and rhythm closely and report any changes or abnormalities to the healthcare provider.
Choice C rationale
Observing the color and amount of urine is not the most important intervention because the color and amount of urine are not directly related to the serum potassium level. The nurse should assess the client’s renal function and fluid balance, but these are not the priority assessments.
Choice D rationale
Comparing muscle strength bilaterally is also not the most important intervention because the muscle strength is not the most sensitive indicator of the serum potassium level. The nurse should evaluate the client’s neuromuscular status and watch for signs of weakness or paralysis, but these are not the priority assessments.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Decreased muscle tone, relaxed jaw muscles, and a sagging mouth are common signs that indicate a client is near death. These changes occur as the body begins to shut down and muscle control diminishes.
Choice B rationale
Clear yellow urine output is not typically associated with the end-of-life stage. As death approaches, urine output usually decreases and may become darker in color.
Choice C rationale
Altered breathing patterns, such as apnea, labored or irregular breathing, and Cheyne-Stokes respiration, are common signs that a client is nearing death. These changes in breathing patterns are due to the body’s decreasing ability to regulate respiratory function.
Choice D rationale
Congestion and increased pulmonary secretions, often referred to as the “death rattle,” are common signs that a client is near death. These noisy respirations occur as the body’s ability to clear secretions diminishes.