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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While over-the-counter laxatives can be effective for relieving constipation, they are typically recommended for short-term use or when dietary and lifestyle changes have not resolved the issue. Regular or frequent use of laxatives can lead to dependence and potentially worsen constipation over time.
B. Increasing water intake is a highly effective way to address constipation. Adequate hydration helps soften the stool, making it easier to pass. Drinking six to eight large glasses of water daily is a good strategy to promote regular bowel movements and prevent constipation.
C. Over-the-counter enemas can provide immediate relief from constipation but should not be used frequently. Enemas are more invasive and can cause discomfort or lead to dependency if used too often. They are typically recommended for occasional use rather than as a first-line solution for chronic constipation.
D. Regular physical activity, such as walking, can help stimulate bowel movements and alleviate constipation. Exercise promotes gut motility and can be an effective part of a comprehensive approach to managing constipation.
Correct Answer is A
Explanation
A. Decreasing the time intervals between toileting can help prevent accidents by ensuring that the resident has more frequent opportunities to use the bathroom. Encouraging Kegel exercises (pelvic floor exercises) can help strengthen the muscles responsible for controlling urination and may improve incontinence.
B. Using disposable undergarments and changing them frequently can help manage incontinence and protect the skin from irritation and breakdown. However, this intervention primarily addresses the symptoms of incontinence rather than the underlying causes.
C. Limiting fluid intake in the evening can reduce the likelihood of nocturia (nighttime urination) and may help in managing urinary incontinence. However, reducing fluid intake can also lead to dehydration and other health issues.
D. Offering emotional support and reassurance is important for the resident’s mental well-being and can help reduce anxiety related to incontinence. Understanding that urinary incontinence is common among older adults can be comforting, but this approach alone does not address the practical management of the condition or contribute to improving urinary control.
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