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?
Start collecting the specimen with the next void.
Begin the collection the next day.
Observe the sample for sediment.
Empty the sample into the 24-hour container.
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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Correct Answer is C
Explanation
Choice A rationale
Asking the client if they understand after each instruction may not be effective if the client is not comfortable expressing confusion or misunderstanding. It does not allow for direct observation of the client’s ability to perform the necessary tasks.
Choice B rationale
Having an interpreter repeat the wound care instructions may be helpful, but it still does not allow for direct observation of the client’s ability to perform the necessary tasks.
Choice C rationale
Having the client demonstrate prescribed wound care is the best way to evaluate the client’s understanding of self-care at home. This allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide feedback and clarification as needed.
Choice D rationale
Providing written instructions in the client’s native language may be helpful, but it does not allow the nurse to directly evaluate the client’s understanding.
Correct Answer is D
Explanation
Choice A rationale
Providing a back rub at bedtime can help promote relaxation and improve sleep quality. However, it does not directly address the issue of wandering, which poses a safety risk for the client. The primary concern should be ensuring the client’s safety by preventing wandering.
Choice B rationale
Applying wrist restraints to prevent wandering is not an appropriate first intervention. Restraints should be used as a last resort when other measures have failed, and they can cause physical and psychological harm to the client. The focus should be on non-restrictive interventions to ensure safety.
Choice C rationale
Administering a PRN sedative prescription may help the client sleep, but it should not be the first intervention. Sedatives can have side effects and may not address the underlying cause of the client’s wandering. Non-pharmacological interventions should be tried first.
Choice D rationale
Leaving the door to the client’s room open slightly allows the client to see and hear staff members as they pass by, which can help reduce feelings of isolation and anxiety. This intervention addresses both the client’s sleep issues and wandering behavior by providing a sense of security and supervision.