A client started a 24-hour urine collection several hours ago. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. Which intervention should the nurse initiate?

Notify the charge nurse of the problem.

Notify the healthcare provider of the situation.

Discard the urine and start another 24-hour period.

Add another hour to the urine collection period.

Answer and Explanation

The Correct Answer is C

A.   While it’s important to inform the charge nurse of any issues with the collection process, this action alone does not address the core problem of the collection being compromised. The charge nurse may offer guidance or assist in deciding the next steps, but the primary focus should be on correcting the collection process to ensure accurate results.
B.   Notifying the healthcare provider can be important, especially if the results of the 24-hour urine collection are critical to the client’s diagnosis or treatment plan. However, it is usually more efficient to first address the issue of the collection itself and then inform the healthcare provider about the results of these corrective actions.
C.   This is the most appropriate action when a mistake occurs in the collection process, such as flushing a voided sample. The integrity of the collection is compromised, and starting a new 24-hour collection period ensures that all samples are accounted for and that the results will be accurate.
D.   Adding extra time to the urine collection period does not compensate for the missed sample. The accuracy of the collection depends on having all urine samples from the full 24-hour period.

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Correct Answer is A

Explanation

A. The Z-track technique helps to prevent medication from leaking into the subcutaneous tissue and minimizes irritation by sealing the medication in the muscle. This is especially important for medications that are known to cause irritation or staining, such as iron supplements or some antipsychotics
B. The length of the needle is not directly related to the use of the Z-track technique. The Z-track method is used to minimize irritation and ensure that the medication is deposited in the muscle rather than leaking into the subcutaneous tissue.
C. The reason for using the Z-track technique is related to preventing irritation and ensuring proper medication delivery, rather than simply following a prescription.
D. The volume of medication is not the primary reason for using the Z-track technique. While the Z-track method can be used for administering larger volumes of medication, the technique's primary purpose is to prevent leakage and reduce tissue irritation.

A. Receiving immune suppressant therapy for cancer. B. Has hyperemia at the site of an acute local infection. C. Lost ten pounds adhering to a low carbohydrate diet. D. Recently received a series of adult immunizations.

Correct Answer is A

Explanation

A. Clients receiving immune suppressant therapy, such as those undergoing treatment for cancer, are at a significantly increased risk for healthcare-associated infections. Immune suppressants weaken the body's ability to mount an effective immune response, making individuals more susceptible to infections.
B. Hyperemia, or increased blood flow to a particular area, can be a sign of an acute local infection. While it indicates the presence of infection, the hyperemia itself does not increase the risk of developing a new or additional healthcare-associated infection.
C. Weight loss, especially if associated with dietary changes, may affect overall health and nutritional status, potentially impairing wound healing and immune function. However, it is not as directly linked to an increased risk of HAIs as immune suppression or invasive procedures.
D. Receiving vaccinations generally aims to enhance immunity and protect against specific infections. Immunizations can help prevent infections but do not increase the risk of healthcare-associated infections. This action is preventive rather than a risk factor for HAIs.

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A client started a 24-hour urine collection several hours ago. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. Which intervention should the nurse initiate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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