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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?

A.

Start collecting the specimen with the next void.

B.

Begin the collection the next day.

C.

Observe the sample for sediment.

D.

Empty the sample into the 24-hour container.

Answer and Explanation

The Correct Answer is A

Choice A rationale

 

Starting to collect the specimen with the next void is the correct action. The 24-hour urine collection for creatinine clearance should start with an empty bladder. The first urine of the day is discarded, and the time is noted.

 

Choice B rationale

 

Beginning the collection the next day is unnecessary and would delay the process. It is important to start the collection as soon as possible to avoid further delays.

 

Choice C rationale

 

Observing the sample for sediment is not relevant to the collection process. The focus should be on starting the collection with the next void.

 

Choice D rationale

 

Emptying the sample into the 24-hour container is incorrect because the first urine sample should be discarded to ensure accurate results.
 


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View Related questions

Correct Answer is D

Explanation

Choice A rationale

Sending an email to facility administrators reporting the action may not be the most immediate or effective way to address the situation. It could delay the necessary intervention and does not ensure that the issue is resolved promptly.

Choice B rationale

Warning the colleague that copying health information is unlawful is important, but it may not adequately address the potential breach of patient privacy and confidentiality. The colleague may already be aware of the laws but still engage in inappropriate behavior.

Choice C rationale

Disposing of the copies and continuing with client care assignments prevents further unauthorized access to patient information but does not address the issue of the colleague’s inappropriate handling of the records. It is essential to report the incident to the appropriate authority for further investigation and follow-up.

Choice D rationale

Communicating the colleague’s activities to the unit charge nurse is the most appropriate action because it informs the person in charge of the unit about the observed behavior, allowing for immediate intervention and potential corrective action. The unit charge nurse can address the situation promptly and ensure that patient privacy and confidentiality are maintained.

Correct Answer is D

Explanation

Choice A rationale

Determining the elasticity of the client’s skin turgor is not directly related to nasopharyngeal suctioning. Skin turgor assessment is typically used to evaluate hydration status and does not provide information about the respiratory status or the need for suctioning.

Choice B rationale

Auscultating the bowel sounds in all four quadrants is unrelated to nasopharyngeal suctioning. Bowel sounds assessment is important for gastrointestinal evaluation but does not help in assessing the respiratory status or the effectiveness of suctioning.

Choice C rationale

Palpating the client’s pedal pulse volume bilaterally is not relevant to nasopharyngeal suctioning. This assessment is used to evaluate peripheral circulation and does not provide information about the respiratory status or the need for suctioning.

Choice D rationale

Observing the client’s skin and mucous membranes is crucial during nasopharyngeal suctioning. This assessment helps determine the client’s oxygenation status and the presence of cyanosis, which can indicate hypoxia. It also helps in identifying any trauma or irritation caused by the suctioning procedure.

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