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
Reviewing the advanced directive document is not an immediate action to address the client’s choking and vomiting. The priority is to clear the airway and prevent aspiration.
Choice B rationale
Irrigating the nasogastric tube with water is not appropriate in this situation as it may worsen the choking and does not address the immediate need to clear the airway.
Choice C rationale
Elevating the head of the bed 45 degrees helps to clear the airway and reduce the risk of aspiration by using gravity to keep the stomach contents down.
Choice D rationale
Performing oropharyngeal suctioning may stimulate gagging and vomiting, which can exacerbate the choking.
Correct Answer is D
Explanation
Choice A rationale
Providing client-focused information is essential, but it does not confirm that the client has understood the critical information. It is a part of the teaching process but not a confirmation strategy.
Choice B rationale
Reinforcing key points with the client helps emphasize important information but does not ensure that the client has learned and understood it. It is a supportive strategy rather than a confirmation method.
Choice C rationale
Observing the client’s body language can provide clues about their understanding and comfort level but is not a definitive way to confirm learning. It should be used in conjunction with other strategies.
Choice D rationale
Asking the client for learning feedback is the most effective strategy for confirming that the client has understood the critical information. It encourages active participation and allows for real-time clarification.